Pediatric Visit 2 To 3 Months Form - Maryland Healthy Kids Program
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1DATE OF SERVICE________________
PEDIATRIC VISIT 2 to 3 MONTHS
NAME___________________________________________ M / F
DATE OF BIRTH_______________ AGE___________
WEIGHT__________/________%
HEIGHT__________/________%
HC________/_______%
TEMP______________
HISTORY:
NUTRITIONAL ASSESSMENT:
Family health history documented & updated?______________
Breast/bottle: Amount & frequency _________________________
Perinatal history documented & updated?_________________
Bowel/bladder: Number of wet ______,
dry ______ in 24 hours?
Concerns: __________________________________________
Number BM's in 24 hours? ________
Education: Hold to feed
Use of pacifier
PSYCHOSOCIAL ASSESSMENT:
If breast fed, Vitamin D
Feed on demand
Sleep:
Child care:
Growth spurts
Avoid solid foods until 4-6 months
Maternal Depression? Yes / No
Recent changes in family: (circle all that apply)
O
R
: (
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE
New members, separation, chronic illness, death, recent move,
Social: Regards face
Alert
Social smile
Loss of job, other_____________________________
Fine Motor: Follows 90 degrees
Grasps
Environment: Smokers in home? Yes / No
Language: Coos
Laughs
Violence Assessment:
History of injuries, accidents? Yes / No
Gross Motor: Head steady when sitting
Hand brought to mouth
Evidence of neglect or abuse? Yes / No
Risk Assessment: TB Circle: Positive / Negative (Annual)
ANTICIPATORY GUIDANCE:
Social: Time out for parent
Parental adjustment
Sibling rivalry
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
Father’s involvement
Appearance/Interaction
Parenting: Comfort often
Infant developing trust
Growth
Holding much of time when awake
___________________________________
Temperaments differ among infants
Skin
Play and communication: Infant seat
Mobiles, music, pictures
_____________________________________
Talk or sing to baby
Objects to kick or bat at
Head/Face/Fontanelles
Eyes/Red reflex/Cover test
Health: Fever/taking temp
Rashes
Diarrhea
Ears
Second hand smoke
Nose
Injury prevention: Rear riding/rear facing infant car seat
Mouth/Gums/Dentition
Smoke detector/escape plan
Hot liquids
Poison control #
_____________________________________
Hot water set at 120º
Water safety (tub/pool)
Neck/Nodes
Choking/suffocation
Firearms (owner risk/safe storage)
Lungs
Fall prevention (heights)
Don’t leave unattended
_____________________________________
Heart/Pulses
PLANS/ORDERS/REFERRALS
Chest/Breasts
. Immunizations ordered ______________________________
1
_____________________________________
2. Second metabolic screen, if not done earlier _____________
Abdomen
3. Follow up newborn hearing screen
_____________________
Genitals
4. Next preventive appointment at 4 months
_____________________________________
5. Referrals for identified problems? (specify)
Extremities/Hips/Feet
________________________________________________
Neuro/Reflexes/Tone
________________________________________________
_____________________________________
Vision (gross assessment)
________________________________________
Hearing (gross assessment)
________________________________________
_______________________________________
________________________________________
_______________________________________
Signatures:
_________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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