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PATIENT NAME __________________________ DATE ________ DOB _________

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

HISTORY DEVELOPMENT
Interval History: Parental Concerns: ________________________________________
Rolls over front to back Grabs objects
Supports head well Interacts with others
Recognizes parents’ voices Smiles and laughs
Clenches a rattle, shakes it Babbles and coos
Sleep Pattern/Position: Sleeping on back? ______ Vision: tracts, follows Reaches with arms
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
Do not microwave bottles No milk or honey No shaking baby
Start solids now Rolling off high places No infant walkers
Extra water not necessary Do not leave alone with sibling Childproof home
Water temperature No smoking in home Acetaminophen after shots
Smoke detectors Sun exposure Car seat / Air bags
ASSESSMENT PLAN
Immunizations: Follow-up visit:
DTP/DTaP, OPV/IPV,
Hepatitis B, HIB