Well Child Exam Form - Early Childhood: 18 Months
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3WELL CHILD EXAM-EARLY CHILDHOOD: 18 Months
DATE
PATIENT NAME
DOB
SEX
PARENT NAME
Allergies
Current Medications
Prenatal/Family History
Chief Complaint
Weight
Percentile
Length
Percentile
Wt. for length
HC
Percentile
Temp.
Pulse
Resp.
BP
Percentile
%
%
%
%
Interval History:
Anticipatory Guidance/Health Education
□ Y
□ N
Patient Unclothed
(√ if discussed)
(Include injury/illness, visits to other health
Safety
Review of
Physical
care providers, changes in family or home)
□ Keep Poison Control number handy
Systems
Exam
Systems
□ Appropriate car seat placed in back seat
N
A
N
A
□ Parents use of seat belts
General
□
□
□
□
□ Use stair gates, safety locks, window guards
Appearance
□ Childproof home - (window guards, cleaners,
□
□
□
□
Skin/nodes
Nutrition
medicines, outlets, guns, dangling cords)
□ Supervise near mowers, driveways, streets
□ Whole milk, cup only
□
□
□
□
Head/fontanel
□ Smoke detectors, keep matches out of sight
□ Solids _______ servings per day
□ Check home for lead poisoning hazards
□ City water
□ Well water
□
□
□
□
Eyes
Nutrition
□ Y □ N
WIC
□ Offer child a new food several times
□
□
□
□
Ears
□ Normal
□ Abnormal
Elimination
□ Let toddler decide what/how much to eat
Sleep
□
□
□
□
□ 3 nutritious meals, 2-3 healthy snacks
Nose
□ Normal (8 – 12 hours)
□ Abnormal
Oral Health
Additional area for comments on page 2
□
□
□
□
□ Don’t put toddler to bed with bottle
Oropharynx
□ Brush toddler’s teeth w/soft toothbrush
Gums/palate/
□
□
□
□
Screening and Procedures:
Child Development and Behavior
teeth
□ Oral Health Risk Assessment
□ Set specific limits, be consistent
□
□
□
□
Neck
□ Delay Toilet Training until child is ready
□ Subjective Hearing -Parental observation/
□ May be anxious with new people/situations
concerns
□
□
□
□
Lungs
□ Interactive talking, playing, singing, reading
□ Subjective Vision -Parental observation/
□ Use simple clear phrases with your child
□
□
□
□
concerns
Heart/pulses
□ Help child focus on another activity when
Standardized Developmental Screening
□
□
□
□
upset
Abdomen
□ Completed
□ Praise good behavior and accomplishments
Tool Used ________________________
□
□
□
□
□ Use discipline to teach, not punish
Genitalia
RESULTS: □ No Risk □ At Risk
Family Support and Relationships
□
□
□
□
Autism Screening
□ Keep family outings short and simple
Spine
□ Completed
□ Allow older children their own space/ toys
□
□
□
□
RESULTS: □ No Risk □ At Risk
Extremities/hips
□ Help child express emotions appropriately
□ Eat meals as a family
Psychosocial/Behavioral Assessment
□
□
□
□
Neurological
□ Substance Abuse, Child Abuse, Domestic
□ Y □ N
Violence Prevention, Depression
□ Y □ N
□ Abnormal Findings and Comments
Screening for Abuse
Other Anticipatory Guidance Discussed:
If Risk:
□ IPPD _________ (result)
( see additional note area on next page)
□ Hct or Hgb ______(result)
Results of visit discussed with parent □ Y □ N
□ Lead level ______ mcg/dl
Plan
Labs □ _____________
□ History/Problem List/Meds Updated
Next Well Check: 24 months of age
□ Fluoride Varnish Applied
Immunizations:
A standardized developmental and autism
□ Immunizations Reviewed, Given & Charted
□ Referrals
screening tool should be administered
(Medicaid required & AAP recommended) at the
– if not given, document rationale
□ WIC
□ Help Me Grow
□ Dentist
18 month visit.
(Refer to AAP immunization guidelines)
□ Children Special Health Care Needs
For M-Chat autism screening tool, go to:
□ Impactsis (OH registry) updated
□ Transportation
□ Other_________
□ Acetaminophen ____ mg. q. 4 hours
chat.PDF
□ Other ________________________________
Provider Signature:
This screening form was adapted by the Ohio Medicaid managed care plans and Ohio Department of Job and Family Services for the
Healthchek-EPSDT Collaborative Performance Improvement Project.
040110
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