Pediatric Visit 9 To 11 Months Form - Maryland Healthy Kids Program
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1DATE OF SERVICE_________________
PEDIATRIC VISIT 9 to 11 MONTHS
NAME___________________________________________
M / F
DATE OF BIRTH_________________
AGE_____________
WEIGHT__________/________%
HEIGHT__________/________%
HC___________/_______%
TEMP______________
HISTORY:
NUTRITIONAL ASSESSMENT:
Family health history documented & updated?____________
Breast/bottle: Amount & frequency _________________
Perinatal history documented & updated?________________
Bowel/bladder: Number of wet____, dry____ in 24 hours?
Reactions to immunizations? Yes / No__________________
Number BM's in 24 hours? _______
Concerns: ________________________________________
Education: Jar/table foods Offer cup
Avoid small hard foods
Encourage self-feeding/finger foods
Expect messiness/playing with
PSYCHOSOCIAL ASSESSMENT:
food
Water only bedtime bottle
Sleep:
Child care:
Recent changes in family:
(circle all that apply)
DEVELOPMENTAL SCREENING:
(With Standardized Tool)
New members, separation, chronic illness, death, recent move,
REQUIRED
loss of job, other___________________________
ASQ:
PEDs Other:
(specify) _________________________
Environment: Smokers in home? Yes / No
Results: Wnl
Areas of Concern:__________________________
Referred: Yes / No Where? ______________________________
Violence Assessment:
History of injuries, accidents? Yes / No
O
R
: (
bserved or
eported)
DEVELOPMENTAL SURVEILLANCE
Evidence of neglect or abuse? Yes / No
Social: Shy with strangers
Plays patty cake
Looks for fallen object
RISK ASSESSMENT:
TB (Annual)
LEAD
Fine Motor: Bangs two cubes
Pincer grasp
Reaches, grabs
Feeds
(Circle)
Pos / Neg
Pos / Neg
self
Drinks from cup
Language: Dada or Mama (specific)
Babbles
PHYSICAL EXAMINATION:
Imitates speech sounds
Wnl
Abn
(describe abnormalities)
Gross Motor: Gets to sitting
Pulls self to stand
Appearance/Interaction
Growth
ANTICIPATORY GUIDANCE:
(Check all that were discussed)
__________________________________
Social: Fear of strangers
Separation anxiety
Skin
Parenting: Emphasize protection over discipline
__________________________________
Temper tantrums: ignore, distract
May need reassurance for separation
Head/Face
anxiety
Eyes/Red reflex/Cover test
Play and communication: Water and sand play
Toys with moving
Ears
Nose
parts, holes, strings to pull
Beginning speech sounds
Mouth/Dentition (# of teeth)
Health: Fluoride if well water
Second hand smoke
__________________________________
Clean teeth with soft toothbrush or cloth
Use sunscreen
Neck/Nodes
Injury prevention: Rear riding/rear facing infant car seat
Lungs
Smoke detector/escape plan
Poison control#
__________________________________
Hot liquids
Hot water set at 120º
Water safety (tub, pool)
Heart/Pulses
Choking/suffocation
Firearms (owner risk/safe storage)
Chest/Breasts
Fall prevention (heights)
Baby proof home
__________________________________
Don’t leave unattended
Abdomen
Genitals
PLANS/ORDERS/REFERRALS
__________________________________
Immunizations ordered ________________________________
1.
Extremities/Hips/Feet
Lead test referral (if positive risk assessment) _______________
2.
Neuro/Reflexes/Tone
Fluoride Varnish Applied? Yes / No_______________________
3.
__________________________________
Next preventive appointment at 12 months
_________________
Vision (gross assessment)
4.
Hearing (gross assessment)
Referrals for identified problems? (specify)___________________
5.
_________________________________________________________
_________________________________________________
_________________________________________________________
_________________________________________________
Signatures:____________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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