Pediatric Visit 18 To 23 Months Form - Maryland Healthy Kids Program 2014
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1DATE OF SERVICE________________
PEDIATRIC VISIT 18 to 23 MONTHS
NAME___________________________________________
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/______%
HEIGHT__________/______%
HC___________/_____%
TEMP______________
NUTRITIONAL ASSESSMENT:
HISTORY REVIEW/UPDATE:
(note changes)
Typical diet:
Medical history updated?______________________________
Family health history updated?_________________________
Education: Prolonged mealtime with playing
Reactions to immunizations? Yes / No___________________
Likes and dislikes change often
Food jags okay
Concerns: ________________________________________
Allow self-feeding
Eat with family
PSYCHOSOCIAL ASSESSMENT
:
DEVELOPMENTAL SCREENING:
(With Standardized Tool)
Sleep:
Child care:
REQUIRED
Recent changes in family:
ASQ:
PEDs Other:
(specify) _________________________
(circle all that apply)
New members, separation, chronic illness, death, recent move,
Results: Wnl
Areas of Concern:__________________________
loss of job, other___________________________
Referred: Yes / No Where? ______________________________
Environment: Smokers in home? Yes / No
MCHAT Required
O
R
(
bserved or
eported)
Violence Assessment:
DEVELOPMENTAL SURVEILLANCE:
Social: Removes clothes
Helps with simple tasks
History of injuries, accidents? Yes / No
Imitates housework
Evidence of neglect or abuse? Yes / No
Fine Motor: Scribbles
Tower of 3-4 cubes
Turns pages
RISK ASSESSMENT:
TB
LEAD
Language: Combines 2 words
Points to 2-4 named body parts
Pos / Neg
Pos / Neg
Follows directions
Names picture (cat, bird, horse, dog, person)
(Circle)
Uses 10-15 words
PHYSICAL EXAMINATION:
Gross Motor: Kicks ball
Throws ball
Walks up steps
Wnl
Abn
(describe abnormalities)
Walks backward
Appearance/Interaction
ANTICIPATORY GUIDANCE:
Growth
Social: Needs to be independent
Stubbornness is normal
___________________________________
Does not share well
Skin
Parenting: Daily routines meet security needs
___________________________________
Child constantly tests parent, self, siblings, environment
Head/Face
“Time out” for hitting/biting
Avoid spanking, slapping
Eyes/Red reflex/Cover test
Forgets rules quickly, needs reminding
Give choices
Ears
Nose
Play and communication: Uses objects for imaginary play
Mouth/Dentition (# of teeth)
Manipulative toys (play dough, sand, paint)
Read stories
___________________________________
Thumb sucking and masturbation common
Neck/Nodes
Favorite toy, transitional object
Lungs
Health: May be toilet ready
Brush teeth Fluoride if well water
___________________________________
Second hand smoke
Use sunscreen
Heart/Pulses
Injury prevention: Infant car seat
Rear riding seat
Chest/Breasts
Hot liquids
Hot water set at 120º
Water safety (tub, pool)
___________________________________
Poison control no.
Choking/suffocation
Baby proof home
Abdomen
Firearms (owner risk/safe storage)
Fall prevention (heights)
Genitals
Don’t leave unattended
Smoke detector/escape plan
___________________________________
Extremities/Hips/Feet
PLANS/ORDERS/REFERRALS:
Neuro/Reflexes/Tone
1. Immunizations ordered _________________________________
___________________________________
2. Review Lead and HCT results
Refer for testing if none _______
Vision (gross assessment)
3. PPD, if risk assessment positive
__________________________
Hearing (gross assessment)
4. Fluoride Varnish Applied? Yes / No
________________________________________________
5. Dental visit advised
or date of last dental visit _____________
________________________________________________
6. Next preventive appointment at 2 Years _____________________
7. Referrals for identified problems: (specify)______________________
_________________________________________________
Signatures:__________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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