Pediatric Visit 30 Months Form - Maryland Healthy Kids Program
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1DATE OF SERVICE________________
PEDIATRIC VISIT 30 MONTHS
NAME_______________________________________________
M / F
DATE OF BIRTH______________
AGE___________
WEIGHT__________/_______%
HEIGHT__________/________%
BMI_______/________%
TEMP_____________
HISTORY REVIEW/UPDATE: (note changes)
NUTRITIONAL ASSESSMENT:
Medical history updated?______________________________
Typical diet:
:
(specify foods)
Family health history updated?_________________________
Education: Offer variety of nutritious foods
5 fruits/vegetables daily
Reactions to immunizations? Yes / No____________________
Child sized portions
Avoid struggles over eating
Eat with family
Concerns: _________________________________________
(With Standardized Tool)
DEVELOPMENTAL SCREENING:
PSYCHOSOCIAL ASSESSMENT:
REQUIRED if not completed at 24 month visit
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___________________________
MCHAT Required
if not completed at 24 month visit
Environment: Smokers in home? Yes / No
O
R
: (
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE
Social: Helps with simple tasks
Puts on clothing
Brushes teeth
Violence Assessment:
Washes and dries hands
Plays interactive games
History of injuries, accidents? Yes / No
Separates from mother
Evidence of neglect or abuse? Yes / No
Fine Motor: Scribbles
Tower of 4-6 cubes
Copies vertical line
Uses spoon well
RISK ASSESSMENT: CHOL
TB
LEAD
(Circle)
Pos / Neg Pos / Neg
Pos / Neg
Language: Combines 2 words
Knows 3-5 named body parts
Follows 2 part directions
Understands cold, tired, hungry
PHYSICAL EXAMINATION:
Gives first and last name
Picks longer line
Wnl
Abn
(describe abnormalities)
Names 1 picture (cat, bird, horse, dog, person)
Gross Motor: Kicks ball
Runs well
Walks up steps
Jumps
Appearance/Interaction
Balances on 1foot-1 second
Pedals tricycle
Growth
Throws ball overhand
___________________________________
(Check all that were discussed)
Skin
ANTICIPATORY GUIDANCE:
Social: Aware of self/different from others
Needs peer contact
___________________________________
Dawdling is normal
Resolving negativism
Head/Face
Power struggles occur
Eyes/Red reflex/Cover test
Parenting: Toilet training (relaxed, praise success)
Sexuality
Ears
Help teach self-control
Offer choice, give simple tasks
Nose
Tantrums (ignore, distract, sympathize)
Mouth/Gums/Dentition
Play and communication: Small table and chairs
___________________________________
Stories and music
Building materials
Neck/Nodes
Health: Avoid bubble baths
Night fears
Brush teeth
Lungs
Fluoride if well water
Biting, kicking stage
Use sunscreen
___________________________________
Physical activity
Second hand smoke
Tick prevention
Heart/Pulses
Injury prevention: Car seat
Rear riding seat
Poison control #
Chest/Breasts
Hot water at 120º
Water safety (tub, pool)
Toddler proof home
___________________________________
Smoke detector/escape plan
Hot liquids
Choking/suffocation
Abdomen
Firearms (owner risk/safe storage)
Fall prevention (heights)
Genitals
PLANS
___________________________________
1. Review immunizations and bring up to date
_________________
Extremities/Hips/Feet
2. Second Lead/HCT test required
if not completed at 24 month
Neuro/Reflexes/Tone
visit______
___________________________________
3. Speech referral if delayed _______________________________
Vision (gross assessment)
4. PPD, if risk assessment is positive
________________________
Hearing (gross assessment)
5. Dental visit advised
Date of Last Dental Exam _______________
_________________________________________________
6. Testing/counseling, if cholesterol risk assessment is positive______
7. Fluoride Varnish Applied? Yes / No________________________
_________________________________________________
8. Next preventive appointment at 3 Years
___________________
_________________________________________________
9. Referrals for identified problems? (specify) _____________________
Signatures:______________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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