2 Months Child Health Checklist Template
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1WELL CHILD VISIT
2 Month
Name ___________________________________Age in Months ______________ Date of Visit ___________________________
Concerns/Discussion
Developmental/Behavioral
Screening/Immunizations
□
□
Screening
Feeding
Coos/Vocalizes
□
□
□
Metabolic/Hemoglobinopathy
Stool/Voiding
Smiles responsively
(results & f/u)
□
□
Illness/Accidents
Reacts to Visual/Auditory cues
□
Hearing Screen (results & f/u)
□
□
Sleeping position
Lifts head/neck (prone position)
□
Vision (exam only)
□
□
Fussy baby/Colic
Temperament/Parent Description
□
____________________________
Child care
Immunizations
____________________________
□
□
Parent returning to work/school
Per ACIP schedule (Record below)
□
Physical Exam
Parent’s health/mood
Anticipatory Guidance
□
□
Other concerns
General
□
□
□
Car seat
Parent/Infant interaction (observe)
Wt ______
% ______
□
Sleep position (back only)
Ht ______
% ______
Nutrition
□
HC _____
% ______
Cigarette smoke
Breast
Monitor growth chart
□
Avoidance of falls
□
□
Length _______ min.
Temp _______
□
Avoiding sleep problems
□
□
Frequency q ______ hrs
Skin (Jaundice)
□
Interaction/Stimulation for baby
□
Nodes
□
Day care selection
Formula
□
Head (Fontanelle/Sutures)
□
□
Appropriate toys
Type ______________________
□
Eyes (Red Reflex)
□
□
Temperature taking
Amount ______ oz.
□
Ears
□
□
Illness instruction
Frequency q ______ hrs.
□
Nose
□
Vitamins (if indicated)
□
Oropharynx
□
Guidance
Neck (Torticollis)
□
□
No solid foods
Chest/Breast
□
□
Breast feeding
Lungs
□
(discourage supplementation)
Cardiovascular
□
Immunizations given:
□
Bottle Feeding
Abdomen
Fe fortified formula only
□
______________________________
Genitalia
No sleeping with bottle
□
Hips (Clicks)
______________________________
□
Neuro
□
Evidence of Neglect/Abuse
______________________________
Record all abnormal findings below.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Assessment and Plan: _______________________________________________________________________________________
________________________________________________________________________________________________________
PHN Referral (if indicated) ___________________________ WIC Referral (if indicated) ________________________________
Physician Signature: ________________________________________________________________________________________
June 2001
Based on Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
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