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PATIENT NAME __________________________ DATE ________ DOB _________

Nursing Assessment: Temp__________________ DRUG ALLERGIES
Weight _______ Percentile _______ Height _______ Percentile ________
Blood Pressure _______

HISTORY DEVELOPMENT
Intellectual / Cultural development
Emotional development
Spiritual development
Interval History: Parental Concerns: ___________________________________
Physical development
Personal Habits Smoking/ Alcohol/ Drugs?_________ Tanner Stages / Puberty
Stools: Consistency/Frequency:__________________ Menstrual cycles (females)
Muscle strength and mass

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? ____________ Grade in School? ______________________________

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

ANTICIPATORY GUIDANCE
Seat belts / Air bag safety School problems Regular physical activity
Gun safety Weight concerns Limit television watching
Teach to swim Supervise activities Neighborhood and sports safety
Smoking / Alcohol/ Drugs No smoking in home Sexual activity / Precautions
Behavior problems Sun exposure / Sunscreen Water / Pool safety

ASSESSMENT PLAN

Immunizations: Follow-up visit: