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PATIENT NAME __________________________ DATE ________ DOB _________
Nursing Assessment: Temp__________________ DRUG ALLERGIES
Weight _______ Percentile _______ Height _______ Percentile ________
Blood Pressure _______

HISTORY DEVELOPMENT
Know own name, address, and phone number
Dresses and undresses Feeds self ____ Counts Throws ball overhand
Interval History: Parental Concerns: ___________________________
Toilet-trained Plays and shares with others
Unlimited vocabulary Uses full sentences
Sleep Pattern: _____________________ Knows colors Uses past tense appropriately
Stools: Consistency/Frequency:___________ Knows own gender Answers “where” questions
Enjoys humor, jokes Copies shapes
Understands simple time concepts
Follows simple commands Understandable by others

PHYSICAL EXAM
Nutrition: Regular Diet
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ___Head _____ EENT __ Vision O.D. ____ O.L. ___ O.U. ____ 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
Age - appropriate car seat Regular bed Life vests when boating
Remove guns from house or lock up Regular diet No talking to strangers
Teach to swim Avoid machinery Helmets for tricycles / bikes
Childproof home Do not leave alone with sibling Syrup of Ipecac / Poisonings
Water temperature No smoking in home Discipline
Behavior Problems Sun exposure / Sunscreen Water / Pool safety
ASSESSMENT PLAN
Immunizations: Follow-up visit:
DTP/DTaP, OPV/IPV,
MMR, BCG