Pediatric Visit 4 To 5 Months Form - Maryland Healthy Kids Program
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1DATE OF SERVICE________________
PEDIATRIC VISIT 4 to 5 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: Can add cereal; use spoon
Iron in formula
If breast fed, Vitamin D and iron
PSYCHOSOCIAL ASSESSMENT:
Introduce single ingredient foods one at a time
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: Smiles
Seeks eye contact with parent
loss of job, other___________________________
Fine Motor: Follows 180 degrees
Grasps rattle
Environment: Smokers in home? Yes / No
Reaches for toy
Hands together
Violence Assessment:
Language: Vocalizes
Coos
Laughs
History of injuries, accidents? Yes / No
Evidence of neglect or abuse? Yes / No
Gross Motor: Rolls over belly to back
Lifts chest up
Risk Assessment: TB Circle: Positive / Negative (Annual)
Prone, lifts head 90 degrees
Head steady when sitting
Bears some weight on legs
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
Appearance/Interaction
ANTICIPATORY GUIDANCE:
Growth
Social: Schedules/daily routines
Sitter
__________________________________
Parenting: Can’t spoil
Different babies have different temperaments
Skin
Play and communication: Hanging toys
___________________________________
Respond to baby’s “conversation”
Age appropriate toys
Head/Face
Choose toys for shape, size and texture
Eyes/Red reflex/Cover test
Ears
Health: Teething, drooling, chewing
Clean teeth
Nose
Second hand smoke
Mouth/Gums
Injury prevention: Rear riding/rear facing infant car seat
__________________________________
Smoke detector/escape plan
Hot liquids
Poison control #
Neck/Nodes
Hot water set at 120º
Water safety (tub, pool)
Lungs
Choking/suffocation
Firearms (owner risk/safe storage)
__________________________________
Fall prevention (heights)
Don’t leave unattended
Heart/Pulses
Chest/Breasts
PLANS/ORDERS/REFERRALS
__________________________________
1. Immunizations by schedule _____
Abdomen
2. Follow up newborn hearing screen _____
Genitals
3. Next preventive appointment at 6 months
__________________________________
4. Referrals for identified problems? (specify)
Extremities/Hips/Feet
______________________________________________________
Neuro/Reflexes/Tone
______________________________________________________
__________________________________
Vision (gross assessment)
______________________________________________________
Hearing (gross assessment)
______________________________________________________
________________________________________________
______________________________________________________
________________________________________________
______________________________________________________
Signatures
________________________________________________________________________________________
:
Maryland Healthy Kids Program
https://mmcp.dhmh.maryland.gov/epsdt
2014
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