Pediatric Visit 6 To 8 Months Form - Maryland Healthy Kids Program
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1DATE OF SERVICE________________
PEDIATRIC VISIT 6 to 8 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?
Reactions to immunizations? Yes / No____________________
Number BM's in 24 hours? _______
Concerns: _________________________________________
Education: Introduce single ingredient food weekly
Offer cup
Jar/table foods
Avoid small hard foods
PSYCHOSOCIAL ASSESSMENT:
Encourage self-feeding
Only water in bedtime bottle
Sleep:
Child care:
Recent changes in family:
(circle all that apply)
O
R
: (
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE
New members, separation, chronic illness, death, recent move,
Social: Shy with strangers
Resists pull toy
Plays peek-a-boo
Loss of job, other____________________________________
Fine Motor: Transfers toy hand to hand
Feeds self crackers
Works
Environment: Smokers in home? Yes / No
for toy out of reach
Violence Assessment:
Language: Dada or Mama (non-specific)
Turns to voice
History of injuries, accidents? Yes / No
Imitates speech sounds
Evidence of neglect or abuse? Yes / No
Gross Motor: Sits alone
Stands holding on
Bears weight on legs
No head lag when pulled to sitting
RISK ASSESSMENT:
TB (Annual)
LEAD
(Circle)
Pos / Neg
Pos / Neg
ANTICIPATORY GUIDANCE:
Social: Fear of strangers
Separation anxiety
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
Parenting: Emphasize protection over discipline
Appearance/Interaction
Temper tantrums: ignore, distract
Growth
May need reassurance for separation anxiety
Skin
Play and communication: Water and sand play
___________________________________
Toys with moving parts, holes, strings to pull
Head/Face/Fontanelles
Beginning speech sounds
Eyes/Red reflex/Cover test
Health: Fluoride if well water
Second hand smoke
Ears
Clean teeth
Use sunscreen
Nose
Injury prevention: Rear riding/rear facing infant car seat
Mouth/Gums/Number of Teeth
Smoke detector/escape plan
Baby proof home
__________________________________
Hot water set at 120º
Poison control #
Neck/Nodes
Choking/suffocation
Fall prevention (heights)
Lungs
Firearms (owner risk/safe storage)
Hot liquids
__________________________________
Water safety (tub/pool)
Don’t leave unattended
Heart/Pulses
Chest/Breasts
PLANS/ORDERS/REFERRALS
__________________________________
1. Immunizations ordered _______________________________
Abdomen
2. Lead test, if positive risk assessment
____________________
Genitals
3. Follow up newborn hearing screen
______________________
__________________________________
4. Fluoride Varnish Applied? Yes / No
Extremities/Hips/Feet
5. Next preventive appointment at 9 months
Neuro/Reflexes/Tone
6. Referrals for identified problems? (specify)
__________________________________
Vision (gross assessment)
__________________________________________________
Hearing (gross assessment)
__________________________________________________
_________________________________________________
___________________________________________________________________________________________
Signatures:
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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