Pediatric Visit 3 Years Form
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1DATE OF SERVICE___________________
PEDIATRIC VISIT 3 YEARS
NAME__________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/_____%
HEIGHT__________/_____%
BMI ______/______%
TEMP_________
BP_____________
(note changes)
NUTRITIONAL ASSESSMENT:
HISTORY REVIEW/UPDATE:
Typical diet
:
Medical history updated? ______________________________
(specify foods)
Family health history updated? _________________________
Education: Offer variety of nutritious foods/snacks
May be picky
Reactions to immunizations? Yes / No____________________
Eats same foods as family
5 fruits/vegetables daily
Concerns: _________________________________________
No sweetened beverages
PSYCHOSOCIAL ASSESSMENT:
(With Standardized Tool)
DEVELOPMENTAL SCREENING:
Sleep:
Child care:
ASQ:
PEDs Other:
(specify) ___________________________
Recent changes in family:
(circle all that apply)
Results: Wnl
Areas of Concern:___________________________
New members, separation, chronic illness, death, recent move,
Referred: Yes / No Where? _______________________________
loss of job, other___________________________
: (Observed or Reported)
DEVELOPMENTAL SURVEILLANCE
Environment: Smokers in home? Yes / No
Social: Dresses self
Separates easily
Plays interactive games
Violence Assessment:
O
Fine Motor: Copies:
______
_______
_______
History of injuries, accidents? Yes / No
Language: Understands 2of 3: cold, tired, hungry
Evidence of neglect or abuse? Yes / No
Understands 3 of 4 prepositions (block is on, under, behind in front of
table)
Speech clear to examiner
Recognizes 3-4 colors
RISK ASSESSMENT: CHOL
TB
LEAD
Uses plurals
Gives first and last name
Knows sex (boy/girl)
Pos / Neg Pos / Neg Pos / Neg
(Circle)
Gross Motor: Balances on 1 foot for 1 second
Jumps well
MENTAL HEALTH ASSESSMENT:
Broad jump
Pedals tricycle
Problem identified?
Yes / No ________________________
Counseling provided? Yes / No________________________
ANTICIPATORY GUIDANCE:
Social: Needs peer contact
Caution with strangers/animals
Sibling
Referral? Yes / No To: ______________________________
rivalry
Develops pride with accomplishments
Caution with strangers/animals
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
Parenting: Time out for serious misbehavior
Read parenting books
Appearance/Interaction
Help child to release energy
Avoid smacking, spanking
Growth
Encourage talk about feelings (instead of misbehaving)
________________________________
Dependency needs alternate with independence
Skin
Special times alone with child
Praise child
________________________________
Play and communication: Excursions, outdoor play, art
Library
Head/Face
Read to child
Make up stories together
Screen TV shows
Eyes/Red reflex
Health: Dental care
Fears
Physical activity
Cover test/Eye muscles
Begin sex education (boy/girl differences, “private parts”, etc)
Ears
Masturbation
Fluoride if well water
Tick prevention
Nose
Second hand smoke
Use sunscreen
Mouth/ Gums/Dentition
Injury prevention: Rear riding car seat
Bicycle helmets
Matches
________________________________
Neck/Nodes
Riding toys in traffic
Smoke detector/escape plan
Lungs
Poisoning (Plants, drugs, chemicals)
Poison control #
Hot water 120º
Choking/suffocation
Fall prevention (heights)
________________________________
Heart/Pulses
Firearms (owner risk/safe storage)
Water safety (tub, pool)
Chest/Breasts
Toddler proof home
________________________________
Abdomen
PLANS/ORDERS/REFERRALS
1. Review immunizations and bring up to date ____________________
Genitals
2. Review Lead and HCT results
Refer for testing if none ________
________________________________
3. PPD, if positive risk assessment
___________________________
Musculoskeletal
4. Testing/counseling, if positive cholesterol risk assessment _______
Neuro/Reflexes
5. Dental visit advised
or date of last visit______________________
________________________________
6. Next preventive appointment at 4 Years _____________________
Vision (gross assessment)
Hearing (gross assessment)
7. Referrals for identified problems:(specify)______________________
_________________________________________________
__________________________________________________________
Signatures:____________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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