2 MONTH OLD WELL CHILD EXAM



BRIGHT FUTURES EXAM: 7/8 YEAR OLD

|NAME: |VISIT DATE: ______/______/______ |DOB: ____/____/____ |

| | |Actual Age: Years______Month |

|MaineCareI.D. #: |NO SHOW |Site Name: |

|Examiner’s Last Name: Examiner’s Servicing Provider #: Site |

|Billing #: |

|KEY: Mark Nl if normal, Ab if abnormal, or Y if yes, N if no, or (( if item done |

|(1) CHILD HISTORY |(3) PHYSICAL EXAM |(5) IMMUNIZATIONS GIVEN |

| | | | |Nl |Ab | |

|1. General health |Nl |Ab | | | | |

| 6. Stool/ urine |Y |N |17. BMI______% | | | |

| 7. Sleeping |Nl |Ab | | | | |

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|ASSESSMENT/ABNORMAL PLAN [refer to line item numbers] |

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|Examiner’s Signature:________________________________________ DATE:______/______/______ RTC in ___ months |

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