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PATIENT NAME __________________________ DATE ________ DOB _________

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

HISTORY DEVELOPMENT
Walks backwards Walks up stairs with help ___ Removes large pieces of clothing
Interval History: Parental Concerns: _________________________________
Follows 2-step commands_____Points to 2-3 body parts _____
Sorts different shapes Names family members
Says 5 to 10 words Turns pages of books
Sleep Pattern/Position: Sleeping on back? ________ Drinks from a cup Gives kisses
Stools: Consistency/Frequency:__________ Takes toys apart and puts them back together

PHYSICAL EXAM
Nutrition:
Continue whole milk and regular table foods
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ___Head _____Fontanelle (should be closed)___ 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
Discontinue bottle if not already done Crib safety / Toddler bed Baby bottle tooth decay
Decrease in appetite normal Regular diet No toys with small parts
No nuts or popcorn Avoid machinery 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 (toddler car seat)/ Air bags Sun exposure / Sunscreen Water / Pool safety

ASSESSMENT PLAN
Immunizations: Follow-up visit:
DTP/DTaP, OPV/IPV