Pediatric Visit 12 To 14 Months Form - Maryland Healthy Kids Program 2014
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1DATE OF SERVICE_________________
PEDIATRIC VISIT 12 to 14 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: Phase out bottle
Table foods
Vitamins
Reactions to immunizations? Yes / No________________
Decreased appetite
Whole milk until age two
Concerns: ______________________________________
Keep offering new foods
Nutritious snacks
PSYCHOSOCIAL ASSESSMENT:
(With Standardized Tool)
Sleep:
Child care:
DEVELOPMENTAL SCREENING:
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____________________________
Environment: Smokers in home? Yes / No
O
R
(
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE:
Violence Assessment:
Social: Fear of strangers
Separation anxiety
History of injuries, accidents? Yes / No________________
Fine Motor: Scribbles
Pincer grasp
Drinks from cup
Evidence of neglect or abuse? Yes / No_______________
Language: Dada or Mama (specific)
1 to 3 words
Indicates wants
RISK ASSESSMENT:
TB
LEAD
(Circle)
Pos / Neg
Pos / Neg
Gross Motor: Stands alone
“Cruises”
Walks
Stoops and
recovers
Plays ball with examiner
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
ANTICIPATORY GUIDANCE:
Appearance/Interaction
Social: Fear of strangers
Separation anxiety
Growth
Parenting: Delay toilet training
Negativism
Autonomy
_______________________________________
Discipline means to teach
Avoid spanking/slapping
Skin
Play and communication: Varied activities
_______________________________________
Singing, naming, reading
Head/Face
Eyes/Red reflex/Cover test
Health: Fever
Fluoride if well water
Brush teeth
Ears
Second hand smoke
Use sunscreen
Nose
Injury prevention: Infant car seat
Rear riding seat
Mouth/Dental/Number of teeth
Hot liquids
Hot water set at 120º
Water safety (tub, pool)
_______________________________________
Choking/suffocation
Poison control #
Baby proof home
Neck/Nodes
Firearms (owner risk/safe storage)
Fall prevention (heights)
Lungs
Don’t leave unattended
Smoke detector/escape plan
_______________________________________
Heart/Pulses
PLANS/ORDERS/REFERRALS
Chest/Breasts
1. Immunizations ordered _________________________________
_______________________________________
Abdomen
2. Lead test/HCT required
_________________________________
Genitals
3. PPD, if positive risk assessment
__________________________
_______________________________________
4. Has parent renewed MA for infant?
Musculoskeletal
5. Dental visit advised
________________________
Neuro/Reflexes/Tone
6. Fluoride Varnish Applied? Yes / No________________________
_______________________________________
7. Next preventive appointment at 15 months
__________________
Vision (gross assessment)
8. Referrals for identified problems? (specify)____________________
Hearing (gross assessment)
__________________________________________________________
__________________________________________________
__________________________________________________________
__________________________________________________
__________________________________________________________
__________________________________________________
__________________________________________________________
Signatures:____________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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