4 Months Child Health Checklist Template
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1WELL CHILD VISIT
4 Month
Name ___________________________________Age in Months ______________ Date of Visit ___________________________
Concerns/Discussion
Screening/Immunizations
□
Head/Neck control
□
□
Screening
Feeding
Lifts chest (prone position)
□
□
□
F/U metabolic and hearing from birth
Stool/Voiding
Temperament/Parent Description
□
□
Vision (exam only)
____________________________
Sleep
____________________________
□
Parent/Sibling adjustment
Immunizations
□
□
Illness/Accidents
Physical Exam
Per ACIP schedule (Record below)
□
Other concerns
□
General
□
Parent/Infant Interaction (observe)
□
Wt ______
% ______
Anticipatory Guidance
Ht ______
% ______
Nutrition
□
Car seat
HC _____
% ______
Breast
□
Monitor growth chart
Sleep position
□
Frequency q ______ hrs
□
□
Temp _______
Avoidance of fall
□
□
Skin
Pet safety
Formula
□
□
□
Nodes
Bathing safety
Type ______________________
□
□
□
Head
Shaken baby/Abuse
Amount ______ oz.
□
□
□
Eyes (Strabismus)
Choking discussion
Frequency q ______ hrs.
□
□
□
Ears
Lead poisoning hazards
Vitamins (if indicated)
□
□
Nose
Plastic bags/Balloon hazards
□
Guidance
□
Oropharynx
Baby “Walker” safety
□
□
Introduction of solids
□
Neck (Torticollis)
Illness instructions
(spoon only)
□
Chest/Breast
□
Breast feeding
□
Lungs
(discuss supplementation)
□
□
Cardiovascular (murmurs)
Bottle Feeding
□
Abdomen
Fe fortified formula only
□
No sleeping with bottle
Genitalia
□
Immunizations given:
Hips (Clicks)
Developmental/Behavioral
□
Neuro (tone/strength)
□
______________________________
Vocalizes/Babbles
□
Evidence of Neglect/Abuse
□
Recognizes parents’ voice
______________________________
□
Grasping objects
□
______________________________
Rolls over
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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