Well Child Exam Infancy: 2 Months
| |WELL CHILD EXAM |Authority: P.A. 116 of 1973 |
| |INFANCY: |Completion: Required |
| |2 MONTH VISIT |Consequences of non-completion: |
| | |Non-compliance of licensing rules. |
|Michigan Department of Health and Human Services |
|Well Child Exam Date | | |
|Patient Name |DOB |Sex |Parent Name |
| | | | |
|Allergies |Current Medications |
| | |
|Prenatal/Family History |
| |
|Weight |Percentile |Length |Percentile |HC |Percentile |Temp. |Pulse |Resp. |BP (if risk) |
| | |% | | |% | | |
| | | | | | | | |
| | | | |C-Section | | |No |
|Interval History: |
|(Include injury/illness, visits to other health care |
|providers, changes in family or home) |
| |
|Apnea | |Yes | |No | |Monitor |
| |Breast every | |hours |
| |Formula | |oz every | |hours |
| |With iron | |Yes | |No |
|Type or brand | |
| |City Water | |Well Water |
|Elimination | |Normal | |Abnormal |
|Sleep | |
| |Normal (2 – 4 hours) | |Abnormal |
|Additional area for comments on page 2 |
|WIC | |Yes | |No |
|Maternal Infant Health Program |
| |Yes | |No |
|Screening and Procedures |
|Neonatal Metabolic Screen in Chart |
| |Yes | |No |Test Date: | | |
| |Normal | |Pending | |Today |
| |Subjective Hearing-Parental observation/concerns |
| |Subjective Vision- Parental observation/concerns |
|Developmental Surveillance | |
| |Social-Emotional | |Communicative |
| |Physical Development | |Cognitive |
|Psychosocial/Behavioral Assessment | |
| |Yes | |No |
|Screening for Abuse | |
| |Yes | |No |
| | |
| |
|Immunizations: |
| |Immunizations Reviewed |
| |Immunizations Given & Charted – if not given, |
| |document rationale |
| |DTaP | |IPV |
| |HepB | |Hib |
| |PCV | |Rota |
| |MCIR Checked/updated |
| |Acetaminophen | |mg. q.4 hours |
| |
|Patient Unclothed | |Yes | |No |
| |Review of |Physical |Systems | |
| |Systems |Exam | | |
| | | | | |
| |N |A |N |A | | |
| | | | | |General Appearance | |
| | | | | |Skin/nodes | |
| | | | | |Head/Fontanel | |
| | | | | |Eyes | |
| | | | | |Ears | |
| | | | | |Nose | |
| | | | | |Oropharynx | |
| | | | | |Gums/palate | |
| | | | | |Neck | |
| | | | | |Lungs | |
| | | | | |Heart/pulses | |
| | | | | |Abdomen | |
| | | | | |Genitalia | |
| | | | | |Spine | |
| | | | | |Extremities/hips | |
| | | | | |Neurological | |
| |
| |Abnormal Findings and Comments |
| |If yes, see additional note area on next page |
| |
|Results of visit discussed with parent |
| |Yes | |No |
| |
|Plan |
| |History/Problem List/Meds Updated |
| |Referrals |
| | |WIC | |Early On® |
| | |Transportation |
| | |Maternal Infant Health Program (MIHP) |
| | |Children Special Health Care Needs |
| | |Other referral | | |
| |Other | | |
| |
|Anticipatory Guidance/Health Education |
|(check if discussed) |
|Safety | |
| |Appropriate car seat placed in back seat |
| |Keep home and car smoke-free |
| |Keep hot liquids away from baby |
| |Don’t leave baby alone in tub or high places; always|
| |keep hand on baby |
| | |
| |Water temp. ................
................
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