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PATIENT NAME _____________________ CHART # __ DATE _____ DOB _________

Nursing Assessment: Temp _______ DRUG ALLERGIES
Weight _______ Percentile _______ Length _______ Percentile ________
FOC _______ Percentile _______ _______

HISTORY DEVELOPMENT
Interval History: Smiles Looks at faces
Parental Concerns: ______________________________________________________
Lifts head to 45º Moves arms and legs____________________________________ Responds to sounds Language: “Ooh/Aah”
Responds to parents’ voices Consolable when cries
Sleep Pattern/Position: Sleeping on back? ________ Vision: tracts, light/dark
Stools: Consistency/Frequency:__________________

PHYSICAL EXAM
Nutrition:
Breast _____ Bottle ______ (Formula _________)
System Normal Abnormalities
Adequate Weight Gain ? (15-45gm/day) ___________ General _________________
Fluoride Supplementation? ______Head ____________Fontanelle ______ EENT ______ Neck____ Chest ____________ Lungs _____________ Heart ______ ____________ Abdomen ________________ Genitalia ___________
Back/Spine ___________ Extremities _________ Hips _____________
Skin ______________ Neurologic ______________

Social History: Primary Caregiver ___________Persons present in household? _________
Any changes ?_________________ Immunodeficient household contacts? ____________ Day Care Center ? ________________________

Family Medical History: Family member with TB? __Child at Lead Exposure Risk? ______

ANTICIPATORY GUIDANCE
Duration of breast or formula feedings Crib safety/Sleeping on back No bottle propping
No microwaving bottles No milk or Honey No shaking baby
No solids necessary Rolling off high places Fever
Extra water not necessary Do not leave alone with sibling Immunizations
Water temperature No smoking in home Acetaminophen after shots
ASSESSMENT PLAN
Immunizations: Follow-up visit:
Hepatitis B