Pediatric Visit 15 To 17 Months Form - Maryland Healthy Kids Program 2014
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1DATE OF SERVICE__________________
PEDIATRIC VISIT 15 to 17 MONTHS
NAME__________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/________% HEIGHT__________/________% HC___________/_______%
TEMP______________
(note changes)
HISTORY REVIEW/UPDATE:
NUTRITIONAL ASSESSMENT:
Medical history updated? ____________________________
Typical diet
(specify foods):
Family health history updated? _______________________
Education: Only water in bedtime bottle
Keep offering new foods
Reactions to immunizations? Yes / No__________________
Strong dislike for certain foods
Phase out bottle, pacifier
Concerns: _______________________________________
(With Standardized Tool)
DEVELOPMENTAL SCREENING:
PSYCHOSOCIAL ASSESSMENT:
ASQ:
PEDs Other:
(specify) ___________________________
Sleep:
Child care:
Results: Wnl
Areas of Concern:___________________________
Recent changes in family:
(circle all that apply)
Referred: Yes / No Where? _______________________________
New members, separation, chronic illness, death, recent move,
loss of job, other___________________________
O
R
: (
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE
Environment: Smokers in home? Yes / No
Social: Imitates affection
Helps with simple tasks
Imitates housework
Violence Assessment:
Fine Motor: Scribbles spontaneously
Uses cup
Feeds self
History of injuries, accidents? Yes / No
Tower of 2 cubes
Evidence of neglect or abuse? Yes / No
Language: 3 words other than Dada/Mama
Immature babbling
RISK ASSESSMENT:
TB
LEAD
Points to 1-3 named body parts
Understands simple commands
Pos / Neg
Pos / Neg
(Circle)
Gross Motor: Crawls up steps
Stoops and recovers
Walks well
Walks backward
Removes garment
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
ANTICIPATORY GUIDANCE:
Appearance/Interaction
Social: Child is egocentric
Loves attention
Growth
Seeks to control others
________________________________
Parenting: Child may bite, hit
Use time out
Skin
Temper tantrums: ignore, distract
Avoid spanking/slapping
________________________________
Discipline is teaching
Dependence verses autonomy needs
Head/Face
Play and communication: Climbing, dancing, riding toys
Eyes/Red reflex/Cover test
Likes to push/pull, empty/fill, open/close
Read stories
Ears
Enjoys household articles
Nose
Health: Regression during illness/stress
Proper shoes
Mouth/Dental/Number of teeth
Teeth brushing
Fluoride if well water
________________________________
Neck/Nodes
Second hand smoke
Use sunscreen
Lungs
Injury prevention: Infant car seat
Rear riding seat
Baby proof home
Hot liquids
Hot water set at 120º
________________________________
Heart/Pulses
Water safety (tub/pool)
Choking/suffocation
Poison control #
Chest/Breasts
Firearms (owner risk/safe storage)
Fall prevention (heights)
Don’t leave unattended
Smoke detector/escape plan
________________________________
Abdomen
Genitals
PLANS/ORDERS/REFERRALS
1. Immunizations ordered ______________________________
________________________________
Musculoskeletal
2. Review lead and HCT results
_________________________
Neuro/Reflexes/Tone
3. Refer for lead and HCT testing if not available
____________
________________________________
4. PPD, if positive risk assessment
Vision (gross assessment)
5. Dental visit advised
or date of last dental exam__________
Hearing (gross assessment)
6. Fluoride Varnish Applied? Yes / No_____________________
_________________________________________________
7. Next preventive appointment at 18 months
_______________
_________________________________________________
Referrals for identified problems? (specify) _________________
8.
Signatures:__________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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