I
Well-child Exam: 4 years Age__________yrs
CG’s name: © Kevin Marks MD, 2012; Last Revised 2-17-2012
( Mom ( Grandparent
Who is at the WCV? ( Dad ( Foster parent
Health or Growth Concerns? ( Sibling(s) ( Other Caregiver
1.
2.
3.
Interval Hx
“5-2-1-0”
5: Fruits & Veggies: 5 servings / day? ( Yes ( No
2: Less than 2 hrs of screen time/ day? ( Yes ( No
1: Activity/ exercise >1 hr/ day ( Yes ( No
0: Zero servings per day of sweetened drinks? ( Yes ( No
Dairy or calcium-rich foods: 800 mg day? ( Yes ( No
Meats, leafy greens, iron-enriched cereals? ( Yes ( No
Foods high in sugar, trans & saturated fats? ( Yes (No
Elimination concerns? _______________________________
Concerns?_________________________________________
“Kindergarten readiness” screening (per AAP)
Administered: ( ASQ ( ASQ:SE ( PEDS ( PEDS:DM
Interpretation: ( Typical/ observe ( Atypical/ action needed
Domains: ( expr. lang. ( recept. lang. ( cognitive
of concern ( fine motor ( gross motor ( SE/ behavior
( self-help/ adaptive ( pre-math ( pre-reading
Bedtime problems ( Excessive daytime sleepiness (Awakenings in pm ( Regularity & duration of sleep ( Snoring
“BEARS”__________________________________________
Circle if: Brushing 2x daily ( Fluoride ( Flossing
Dentist ( referred to ( has seen:_____________________
Updated in Problem List / EMR
________
_______________________________________
__________________________________________________
Tobacco exposure? ( Yes ( No DV? ( Yes ( No
Vision: R __ / ____ Stereopsis (Random Dot E
Monocular or stereogram) ( Pass > 4/5
distance acuity L______/_______ ( Fail < 3/5
( Pass ( Refer ( Uncooperative
Hearing: R ____ @ ____db L __ @ ____ db (with pure tone audiometry, 500 to 4000 Hz)
( Pass ( Refer ( Uncooperative so OAE needed
Vitals & Growth Parameters
T (C/(F ax/rect/tymp P R BMI __ %
Ht _ cm ( ____ _%) Wt kg ( ____ %)
BP _ _ / ____ 90th%tile: M 102/ 62
F 101/ 64
GEN
HEENT
Chest/Lungs
CV/Heart
ABD
GU
Skin
MSK/Spine
Neuro
Parent-Child Interaction
Other:
Growth: ( typical ( obese ( overweight ( underweight/ FTT
Development & Behavior: see above
Other: see EMR problem list
__________________________________________________
__________________________________________________
4 yr WCV handout (Bright Futures: Early Childhood)
ROR book & literacy counseling
( “Healthy Habits” / obesity prevention handout + counseling
( Fluoride 0.5mg + MTV w/ iron & Vit D 600 IU PO qd
( ECSE referral + care coordination phone #
( Head Start/ other high-quality preschool recommended
❑ Kindergarten readiness: encourage high-quality preschool/ Head Start; pre-math, pre-reading, writing skills at home
❑ Reading daily; encourage letter and word recognition
❑ Calm bedtime ritual; mealtimes should be without TV
❑ Expect child to be curious about their body; use correct terms, answer the child’s questions
❑ Saftey: ride in back in car safety seat until child reaches highest weight or height allowed by manufacturer, then switch to a belt-positioning booster seat
❑ Limit TV/ media 1-2 hrs qd; no TV in bedroom
Refer to EMR for vaccines given, CDC handouts given
( AAP “Refusal to Vaccinate” form signed
( Vaccine counseling
( Next routine well-child visit
( Early return OV
( SE (ASQ:SE) screening needed (per AAP)
( Follow-up ADHD assessment needed
-----------------------
EPSDT
( Hx/Nutr/Devel
( Unclothed PE
( Labs
( Health Educ
( Vision Screen
( Hearing Screen
( Immunizations
( Dental Referral
History (
Nutrition / Activity (
Dev./Behav./Learning (
Sleep
Dental (
PMH, Meds, Allergies
Family Hx
Social Hx
PE: Sensory Screening ( ((
PE (
Assessment
Plan
Guidance (
Immunizations (
Follow up / Return
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