WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment...

3
WELL CHILD/6 to 9 MONTHS Referrals Assessment and Plan Physical Examination (Unclothed) No. 3 of 7 MR #: __________________________ NL ABN ❏❏ General Appearance _______________________________________________ ❏❏ Head / Fontanelle _________________________________________________ ❏❏ Eyes / Red Reflex _________________________________________________ ❏❏ Ears ____________________________________________________________ ❏❏ Nose ___________________________________________________________ ❏❏ Mouth/Throat, and Teeth ____________________________________________ ❏❏ Lungs ___________________________________________________________ ❏❏ Heart / Pulses ____________________________________________________ ❏❏ Abdomen ________________________________________________________ ❏❏ Genitalia _________________________________________________________ ❏❏ Extremities / Hips __________________________________________________ ❏❏ Back ____________________________________________________________ ❏❏ Skin_____________________________________________________________ ❏❏ Neurologic _______________________________________________________ _______________________________________________________________________ ❏ Well Child ❏ Additional concerns or identified special health needs (detail below): ❏ Dev Delay ❏ Seizure(s) ❏ Wheezing/RAD ❏ Dental ❏ Other: Assessment: ____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Plan:___________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding ❏ Referral Made: ________________________________________________________ F/U Next Visit: ____________________________________________________________ Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ). x ✔ DRUG ALLERGIES WEIGHT IF INDICATED: PULSE Ox TEMP BP RR P HEIGHT HEAD CIRC. NAME ACCOMPANIED BY PHONE 1 PHONE 2 AGE YRS MOS DOB ❏ M ❏ F ❏ 1st Visit ❏ Periodic Visit DATE/TIME INSURANCE ID # % % % ❏ lb. ❏ kg. ❏ in. ❏ cm. ❏ in. ❏ cm. History and physical reviewed with resident at time of visit, agree with the diagnosis of and treatment Provider Print Signature Nurse Print Signature Other Print Signature Version 1.1 (5/06) History/Parent Concerns Social/Family History Review of Systems Anticipatory Guidance Provided Immunizations/Screens Interval History: ❏ None ❏ Newborn History Previously Taken _________________________________________________________________ _________________________________________________________________ Current Medications: _______________________________________________ _________________________________________________________________ ❏ Completed ____________________________________________________ ________________________________________________________________ ________________________________________________________________ Child Care: ❏ Yes ❏ No Type: __________________________________ ❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________ _________________________________________________________________ ❏ Elimination Assessed ___________________________________________ ❏ Environment Assessed __________________________________________ ❏ Sleep Patterns Assessed ________________________________________ ❏ Development Assessed: (Use Table on Back) ________________________ OR ❏ DENVER DEVEL. II ADMINISTERED OR ❏ OTHER TOOL ADMINISTERED: ________________________________ Comments:________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK Anemia Screen (HGB/HCT): ❏ Ordered ❏ Deferred until 1 year Lead Risk: ❏ No ❏ Yes If, yes: ❏ Test Ordered ❏ Immunizations Reviewed Immunizations Ordered: ❏ Rotavirus ❏ DTaP ❏ IPV ❏ HIB ❏ HBV ❏ HIB/HBV ❏ DTAP/IPV/HBV ❏ PCV7 ❏ Influenza ❏ Medical / Religious Exemptions: ___________________________________ Immunization Comments: ____________________________________________ _________________________________________________________________ COPY FOR DC DOH

Transcript of WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment...

Page 1: WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment and Plan Physical Examination (Unclothed) ... Child Care: Yes No ... NURSING NOTES:PAIN?

WELL CHILD/6 to 9 MONTHS

Referrals

Assessment and Plan

Physical Examination (Unclothed)

No. 3 of 7

MR #: __________________________

NL ABN

❏ ❏ General Appearance _______________________________________________

❏ ❏ Head / Fontanelle _________________________________________________

❏ ❏ Eyes / Red Reflex _________________________________________________

❏ ❏ Ears ____________________________________________________________

❏ ❏ Nose ___________________________________________________________

❏ ❏ Mouth/Throat, and Teeth ____________________________________________

❏ ❏ Lungs ___________________________________________________________

❏ ❏ Heart / Pulses ____________________________________________________

❏ ❏ Abdomen ________________________________________________________

❏ ❏ Genitalia _________________________________________________________

❏ ❏ Extremities / Hips __________________________________________________

❏ ❏ Back ____________________________________________________________

❏ ❏ Skin_____________________________________________________________

❏ ❏ Neurologic _______________________________________________________

_______________________________________________________________________

❏ Well Child ❏ Additional concerns or identified special health needs (detail below):

❏ Dev Delay ❏ Seizure(s) ❏ Wheezing/RAD ❏ Dental ❏ Other:

Assessment: ____________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Plan:___________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding

❏ Referral Made: ________________________________________________________

F/U Next Visit: ____________________________________________________________

Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔

DRUG ALLERGIES

WEIGHT

IFINDICATED:

PULSE Ox TEMP BPRR P

HEIGHT HEAD CIRC.

NAME

ACCOMPANIED BY PHONE 1 PHONE 2

AGE

YRS MOS

DOB ❏ M

❏ F

❏ 1st Visit ❏ Periodic Visit

DATE/TIME INSURANCE ID #% % %❏ lb.

❏ kg.❏ in.❏ cm.

❏ in.❏ cm.

History and physical reviewed with resident at time of visit, agree with the diagnosisof and treatment

Provider Print Signature

Nurse Print Signature

Other Print Signature

Version 1.1 (5/06)

History/Parent Concerns

Social/Family History

Review of Systems

Anticipatory Guidance Provided

Immunizations/Screens

Interval History: ❏ None ❏ Newborn History Previously Taken

_________________________________________________________________

_________________________________________________________________

Current Medications: _______________________________________________

_________________________________________________________________

❏ Completed ____________________________________________________

________________________________________________________________

________________________________________________________________

Child Care: ❏ Yes ❏ No Type: __________________________________

❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________

_________________________________________________________________

❏ Elimination Assessed ___________________________________________

❏ Environment Assessed __________________________________________

❏ Sleep Patterns Assessed ________________________________________

❏ Development Assessed: (Use Table on Back) ________________________

OR ❏ DENVER DEVEL. II ADMINISTERED

OR ❏ OTHER TOOL ADMINISTERED: ________________________________

Comments:________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK

Anemia Screen (HGB/HCT): ❏ Ordered ❏ Deferred until 1 year

Lead Risk: ❏ No ❏ Yes If, yes: ❏ Test Ordered

❏ Immunizations Reviewed

Immunizations Ordered: ❏ Rotavirus

❏ DTaP ❏ IPV ❏ HIB ❏ HBV

❏ HIB/HBV ❏ DTAP/IPV/HBV ❏ PCV7 ❏ Influenza

❏ Medical / Religious Exemptions: ___________________________________

Immunization Comments: ____________________________________________

_________________________________________________________________

COPY FOR DC DOH

Page 2: WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment and Plan Physical Examination (Unclothed) ... Child Care: Yes No ... NURSING NOTES:PAIN?

WELL CHILD/6 to 9 MONTHS

Referrals

Assessment and Plan

Physical Examination (Unclothed)

No. 3 of 7

MR #: __________________________

NL ABN

❏ ❏ General Appearance _______________________________________________

❏ ❏ Head / Fontanelle _________________________________________________

❏ ❏ Eyes / Red Reflex _________________________________________________

❏ ❏ Ears ____________________________________________________________

❏ ❏ Nose ___________________________________________________________

❏ ❏ Mouth/Throat, and Teeth ____________________________________________

❏ ❏ Lungs ___________________________________________________________

❏ ❏ Heart / Pulses ____________________________________________________

❏ ❏ Abdomen ________________________________________________________

❏ ❏ Genitalia _________________________________________________________

❏ ❏ Extremities / Hips __________________________________________________

❏ ❏ Back ____________________________________________________________

❏ ❏ Skin_____________________________________________________________

❏ ❏ Neurologic _______________________________________________________

_______________________________________________________________________

❏ Well Child ❏ Additional concerns or identified special health needs (detail below):

❏ Dev Delay ❏ Seizure(s) ❏ Wheezing/RAD ❏ Dental ❏ Other:

Assessment: ____________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Plan:___________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding

❏ Referral Made: ________________________________________________________

F/U Next Visit: ____________________________________________________________

Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔

DRUG ALLERGIES

WEIGHT

IFINDICATED:

PULSE Ox TEMP BPRR P

HEIGHT HEAD CIRC.

NAME

ACCOMPANIED BY PHONE 1 PHONE 2

AGE

YRS MOS

DOB ❏ M

❏ F

❏ 1st Visit ❏ Periodic Visit

DATE/TIME INSURANCE ID #% % %❏ lb.

❏ kg.❏ in.❏ cm.

❏ in.❏ cm.

History and physical reviewed with resident at time of visit, agree with the diagnosisof and treatment

Provider Print Signature

Nurse Print Signature

Other Print Signature

Version 1.1 (5/06)

History/Parent Concerns

Social/Family History

Review of Systems

Anticipatory Guidance Provided

Immunizations/Screens

Interval History: ❏ None ❏ Newborn History Previously Taken

_________________________________________________________________

_________________________________________________________________

Current Medications: _______________________________________________

_________________________________________________________________

❏ Completed ____________________________________________________

________________________________________________________________

________________________________________________________________

Child Care: ❏ Yes ❏ No Type: __________________________________

❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________

_________________________________________________________________

❏ Elimination Assessed ___________________________________________

❏ Environment Assessed __________________________________________

❏ Sleep Patterns Assessed ________________________________________

❏ Development Assessed: (Use Table on Back) ________________________

OR ❏ DENVER DEVEL. II ADMINISTERED

OR ❏ OTHER TOOL ADMINISTERED: ________________________________

Comments:________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK

Anemia Screen (HGB/HCT): ❏ Ordered ❏ Deferred until 1 year

Lead Risk: ❏ No ❏ Yes If, yes: ❏ Test Ordered

❏ Immunizations Reviewed

Immunizations Ordered: ❏ Rotavirus

❏ DTaP ❏ IPV ❏ HIB ❏ HBV

❏ HIB/HBV ❏ DTAP/IPV/HBV ❏ PCV7 ❏ Influenza

❏ Medical / Religious Exemptions: ___________________________________

Immunization Comments: ____________________________________________

_________________________________________________________________

Page 3: WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment and Plan Physical Examination (Unclothed) ... Child Care: Yes No ... NURSING NOTES:PAIN?

WELL CHILD/6 to 9 MONTHSADDITIONAL COMMENTS: ________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

NURSING NOTES: PAIN? ❏ No ❏ Yes Score ______________________________

❏ Management: See Treatment Plan

Interpreter Used? ❏ Yes ❏ No Primary Language:________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

INSTRUCTIONSIf the action was taken or completed, the open box must be marked (❏ or ❏).

If the child is enrolled in Medicaid, please be sure to print and sign your name in the space provided and fax or mail the completed form to:

HEALTHCHECK REGISTRY, POST OFFICE BOX 77498WASHINGTON, DC 20013-7749

FAX: (202) 541-5907

For further information on HealthCheck or Bright Futures go to www.brightfutures.org/healthcheck.html

BEHAVIOR AND DEVELOPMENT

Age Gross Motor Fine Motor Communication Social

6 Months

9 Months

__ Reaches for objects

__ Pincer grasp

__ Babbles__ Turns to voice__ Imitates sounds

__ Responds to name__ Jabbers__ Dada/Mama (nonspecific)__ Waves bye-bye

__ Feeds self__ Works for toy

__ Peekaboo__ Stranger anxiety

■ NUTRITION• Breastfeeding• Vitamins• Formula• No juice• Solid foods/finger foods

- May start rice cereal- Introduce only 1 solid food

every week• Safe foods/avoid choking• Elimination• Review of WIC status

At 9 months:• Transition cup• No cow’s milk

■ ORAL HEALTH• Clean teeth, gums (water only)• No bottle in crib

■ IMMUNIZATIONS EXPLAINED■ INFANT CARE

• Skincare• Good sleep habits• Thermometer training

■ BEHAVIOR & DEVELOPMENT■ PARENT-INFANT INTERACTION

• Temperament• Talk/read/sing to baby• Parental depression• Sibling rivalry• Family relationships• Simple rules/limits• Stranger anxiety

■ INJURY AND ILLNESS PREVENTION• Crib safely • Child safety seat• Falls• Burns• Water heater• Smoke detectors• Violence/guns• Childproofing• Electrical outlets/cords• No walkers• Back to sleep• Passive smoking• Lead risks (> 10 ug/dL, high

risk)• Limit TV

• Sun safety• Water safety

Suggested age appropriate topics for anticipatory guidance:

x✔

__ Sits briefly__ Roll back to front

__ Pulls to stand__ Stands holding on__ Gets to sitting


Child Development Milestones – 3 months...Child Development Milestones – 3 months The majority of children will achieve these development milestones by the time they turn 3 months.

Child Development Milestones – 3 months...Child Development Milestones – 3 months The majority of children will achieve these development milestones by the time they turn 3 months.

ABCof Child Abuse FRACTURES - bmj.com · Growthchartof14monthold girlwithfracturedtibia and fibulaincasedescribed overleaf. Patternoffailureto thrivedevelopedfromageof4 months, whencarewas

ABCof Child Abuse FRACTURES - bmj.com · Growthchartof14monthold girlwithfracturedtibia and fibulaincasedescribed overleaf. Patternoffailureto thrivedevelopedfromageof4 months, whencarewas

Child Development 3 – 6 months – HP3419

Child Development 3 – 6 months – HP3419

Baby's milestones six to twelve months · Baby's milestones six to twelve months - maternal and child health fact sheet Keywords: baby's, baby, milestone, milestones, 6-12 months,

Baby's milestones six to twelve months · Baby's milestones six to twelve months - maternal and child health fact sheet Keywords: baby's, baby, milestone, milestones, 6-12 months,

Infant & Child Physical Activity - Nebraska Dept of Education€¦ ·  · 2017-07-31Infant & Child Physical Activity . ... Toddlers (13-24 months) 90 ... • Professional development

Infant & Child Physical Activity - Nebraska Dept of Education€¦ ·  · 2017-07-31Infant & Child Physical Activity . ... Toddlers (13-24 months) 90 ... • Professional development

Child Development: 11-12 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

Child Development: 11-12 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

Information about Food Intolerance Testing · Adult Food Intolerance Test £100 Child Food Intolerance Test £75 Adult retest [3 months after first test] £40.00 Child retest [3 months

Information about Food Intolerance Testing · Adult Food Intolerance Test £100 Child Food Intolerance Test £75 Adult retest [3 months after first test] £40.00 Child retest [3 months

Infant/Toddler Credential Crosswalk Child Development ... · Young Infants (birth–8 months) Mobile Infants (9–17 months) Toddlers (18–36 months) Candidates must achieve this

Infant/Toddler Credential Crosswalk Child Development ... · Young Infants (birth–8 months) Mobile Infants (9–17 months) Toddlers (18–36 months) Candidates must achieve this

Prenatal Diet and Child Growth at 18 Months · ARTICLE Prenatal Diet and Child Growth at 18 Months Jodie M. Dodd, MD, PhD,a, b Jennie Louise, PhD,a, c Andrea R. Deussen, BHSc(Hon),

Prenatal Diet and Child Growth at 18 Months · ARTICLE Prenatal Diet and Child Growth at 18 Months Jodie M. Dodd, MD, PhD,a, b Jennie Louise, PhD,a, c Andrea R. Deussen, BHSc(Hon),

Caring for your child - 9 months · 2018-05-24 · Caring for your Child 9 Months You will need to return to your clinic every 2 months to check your child’s growth. At the 1 year

Caring for your child - 9 months · 2018-05-24 · Caring for your Child 9 Months You will need to return to your clinic every 2 months to check your child’s growth. At the 1 year

EDGAR CHAMBERS IV · Nestle’ Child Nutrition (Gerber) - 3 internships – 6 months . EDGAR CHAMBERS IV, cont. ... Cadbury Schweppes, CT – 3 months Schick Wilkinson Sword, Milford

EDGAR CHAMBERS IV · Nestle’ Child Nutrition (Gerber) - 3 internships – 6 months . EDGAR CHAMBERS IV, cont. ... Cadbury Schweppes, CT – 3 months Schick Wilkinson Sword, Milford

Pregnancy Smoking And Child Outcomes from birth to 15 Months: Findings from Northeast Tennessee

Pregnancy Smoking And Child Outcomes from birth to 15 Months: Findings from Northeast Tennessee

Child Development: 5 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

Child Development: 5 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

TODDLER - Ohio Child Care Resource and Referral … - Infant Toddler Field... · Toddler 2 Ohio’s Infant & Toddler Field Guide ... Juanita, 22 months, and Cole, 28 months, ... 24

TODDLER - Ohio Child Care Resource and Referral … - Infant Toddler Field... · Toddler 2 Ohio’s Infant & Toddler Field Guide ... Juanita, 22 months, and Cole, 28 months, ... 24

12 Months Old Development Stages Learning child development stages of a 12 month old!

12 Months Old Development Stages Learning child development stages of a 12 month old!

Assess and Classify the Sick Child Age 2 Months up to 5 Years Health...1 INTRODUCTION The chart ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS describes how to assess

Assess and Classify the Sick Child Age 2 Months up to 5 Years Health...1 INTRODUCTION The chart ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS describes how to assess

ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO …

ASSESS AND CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO …

Parent-Child Attunement Therapy (PCAT): An Adaptation ......Parent-Child Attunement Therapy (PCAT): An Adaptation Overview of PCIT for Children Ages 12 Months-24 Months Emma Girard,

Parent-Child Attunement Therapy (PCAT): An Adaptation ......Parent-Child Attunement Therapy (PCAT): An Adaptation Overview of PCIT for Children Ages 12 Months-24 Months Emma Girard,

Child Development: 3 – 4 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

Child Development: 3 – 4 months. The Power of Partnership The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training.

Glossary of Child Support Terms - des.az.gov · with the noncustodial parent. When an Order specifies the NCP does not owe child support for specific months (the child is in the NCP's

Glossary of Child Support Terms - des.az.gov · with the noncustodial parent. When an Order specifies the NCP does not owe child support for specific months (the child is in the NCP's