I
Well-Child Visit: 18 months Age______mo
CG’s name: © Kevin Marks MD, 2012; Last Revised 2-22-2012
( Mom ( Grandparent
Who is at the WCV? ( Dad ( Foster parent
( Sibling(s) ( Other Caregiver
Health or growth concerns?
1.
2.
3.
Interval Hx? _____
Breastfeeding ( Yes ( No
Cow’s milk? ( Yes ( No Whole or 2%? oz/day
Fe-rich cereal 2x qd? ( Yes ( No
Meats, fish, eggs, soy? ( Yes ( No
Vegetables, fruits? ( Yes ( No
Age-appropriate finger foods? ( Yes ( No Fruit juice, sugars? ( Yes ( No
Elimination concerns? ( Yes ( No ____________________
Concerns?_______________
__________________________________________________ General developmental & ASD screenings (per AAP)
Administered: ( ASQ ( 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 ( other
Administered: ( M-CHAT circle if: ( + ) or ( - ) ( Other
Circle if: No bottle in bed ; Brushing; Fluoride
( Referred to dentist
( Fluoride varnish + handout
__________________________________________
Updated in Problem List / EMR
________
__________________________________________________
Tobacco exposure? ( Yes ( No DV? (Yes ( No
( Cap Hemogram or HemoCue (If Hgb2nd story room; prevent burns; install smoke detectors
Refer to EMR for vaccines given, CDC handouts given
( Vaccine counseling
( Refusal to vaccinate AAP form signed
( Next routine well-child visit
( Early return OV
( SE (ASQ:SE) screening needed (per AAP)
( ASD assessment/ M-CHAT Follow-up Interview needed
-----------------------
EPSDT
( Hx/Nutr/Devel
( Unclothed PE
( Labs
( Health Educ
( Vision Screen
( Hearing Screen
( Immunizations
( Dental Referral
History (
Nutrition / Activity (
Dev./Behav./Learning (
Dental (
Sleep
PMH, Meds, Allergies
Family Hx
Social Hx
Medical Screening (
PE: Sensory Screening ((
PE (
Assessment
Plan
Guidance (
Immunizations (
Follow up / Return
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- part i foundations of communication
- early steps operations guide
- suicide risk assessment guide veterans affairs
- tri service workflow tswf
- tri service workflow tswf innovations in military
- system design document template veterans affairs
- child health services early and periodic screening
- website design questionnaire
Related searches
- how do i sell stocks i own
- i ask or i asked
- synonyms for i believe or i think
- i choose or i chose
- i think i found the one
- i bet or i ll bet
- humss cw mpig i 11 humss cw mpig i 12 humss cw mpig i 13
- i took a deep breath and listened to the old brag of my heart i am i am i am
- i feel like the things i should say are the things i can t say
- i have loved words and i have hated them and i hope i have made them right
- i looked and looked at her and i knew as clearly as i know th
- i e 577 02 9006 yah shua 577 02 9006 holy spirit i i e yah shu