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PATIENT NAME __________________________ DATE ________ DOB _________

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

HISTORY DEVELOPMENT
Cruises yes/no Enjoys games
Sits without support Clasps hands
Interval History:
Parental Concerns: ______________________________________________________
Rolls over both ways Creeps / Crawls __________ Responds to name Pincer Grasp ______
Imitates sounds Understands “No”
Sleep Pattern/Position?_______________________ Plays “peek-a-boo” Turns pages
Stools: Consistency/Frequency:____________ Drinks from a cup Says “mama”, “dada”

PHYSICAL EXAM
Nutrition:
Breast _____ Bottle ______ (Formula _________) Solids foods - cereals,
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 toys with small parts
No nuts or popcorn Rolling off high places No plastic bags / marbles
Childproof home Do not leave alone with sibling Syrup of Ipecac / Poisonings
Water temperature No smoking in home Acetaminophen after shots
Car Seat / Air Bags Sun exposure Water / Pool safety
ASSESSMENT PLAN
Immunizations: Follow-up visit:
Hepatitis B