Pediatric Visit 4 To 5 Years Form
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1DATE OF SERVICE___________________
PEDIATRIC VISIT 4 TO 5 YEARS
NAME__________________________________________
M / F
DATE OF BIRTH_________________
AGE_____________
WEIGHT__________/_____%
HEIGHT__________/_____%
BMI ______/______% TEMP______________
BP_____________
(note changes)
NUTRITIONAL ASSESSMENT:
HISTORY REVIEW/UPDATE:
Medical history updated? Yes / No_____________________
Typical diet:
:
(specify foods)
Family health history updated? Yes / No________________
Education: Choose from food guide pyramid
2hrs or less TV/day
Reactions to immunizations? Yes / No__________________
Child can help prepare food for meals
Mealtime can be fun
Concerns: _______________________________________
5 fruits/vegetables daily
Food jags
1 or more hrs. physical activity
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: Toilets alone
Dresses self
Plays in group
Violence Assessment:
Separates from parent easily
History of injuries, accidents? Yes / No
O
Fine Motor: Copies:
______
_______
_______
Evidence of neglect or abuse? Yes / No
Uses scissors
Draws person, 3 parts
RISK ASSESSMENT: CHOL
TB
LEAD
Language: Knows: What is:- spoon ; shoe ; door ;-made of?
Fluent sentences
Recognizes 3-4 colors
Defines 6-9 words: Ball
(Circle)
Pos / Neg
Pos / Neg Pos / Neg
Lake
Desk
House
Banana
Curtain
Ceiling
Fence
Knows 2-3 opposites: fire is hot, ice is __ ; mom is woman, dad is __ ;
MENTAL HEALTH ASSESSMENT:
horse is big, mouse is ___
Problem identified?
Yes / No ________________________
Counseling provided? Yes / No _______________________
Gross Motor: Balances on 1 foot for 10 seconds (2-3 times)
Referral? Yes / No To: ______________________________
Hops
Heel-toe walk
Catches bounced ball
ANTICIPATORY GUIDANCE:
PHYSICAL EXAMINATION
Social: School readiness
Enrolled in Pre-K/K
School avoidance
Wnl
Abn
(describe abnormalities)
Management of aggression
Promote self-help skills
Appearance/Interaction
Caution with strangers/animals
Growth
________________________________
Parenting: Allow separation
Promote initiative, creativity
Skin
Awareness of ADHD and learning disabilities
________________________________
Play and communication: Monitor TV use
Small chores
Head/Face
Creative, active and group play
Eyes/Red reflex
Health: Dental care
Fluoride if well water
Bedwetting
Fears
Cover test/Eye muscles
Nightmares
Leg aches
Normal sexual curiosity; simple answers
Ears
Masturbation
Oedipal complex
Use sunscreen
Nose
Tick prevention
Second hand smoke
Mouth/ Gums/Dentition
Injury prevention: Booster seat (up to 4’9”)
Ride in back seat
________________________________
Neck/Nodes
Riding toys in traffic environment
Bicycle helmets
Matches
Lungs
Choking/suffocation
Hot water 120º
Water safety (tub, pool)
Poisoning (Plants, drugs, chemicals)
Poison control #
________________________________
Heart/Pulses
Fall prevention (playground)
Smoke detector/escape plan
Chest/Breasts
Firearms (look alike toys, owner risk/safe storage)
________________________________
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 _____________________________
Vision (gross assessment)
7. Referrals for identified problems: Yes / No (specify)
Hearing (gross assessment)
_________________________________________________
_________________________________________________________
Signatures:____________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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