Well Child Exam Form - Early Childhood: 18 Months Page 2
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3WELL CHILD EXAM-EARLY CHILDHOOD: 18 Months
DATE
PATIENT NAME
DOB
Developmental Questions and Observations
A standardized developmental and autism screening tool should be administered (Medicaid required and AAP
recommended) at the 18 month visit.
Ask the parent to respond to the following statements about the toddler:
Yes
No
□
□
Please tell me any concerns about the way your toddler is behaving or developing:
________________________________________________________________
□
□
My toddler likes to be with
me.
□
□
My toddler is interested in people, places and things.
□
□
My toddler shows different feelings.
□
□
My toddler feeds self with fingers/spoon and drinks from a cup.
□
□
My toddler can stack 2 – 3 blocks.
Ask the parent to respond to the following statements:
Yes
No
□
□
I am sad more often than I am happy.
□
□
I have people who help me when I get frustrated with my toddler.
□
□
I am enjoying my time with my toddler.
□
□
I have time for myself, partner and friends.
□
□
I feel safe with my partner.
Developmental Milestones
A standardized developmental and autism screening tool should be administered (Medicaid required) at the 18 month visit. (Medicaid
required-Tool Used:__________________________________)
. For M-CHATs Screening Tool go to
. Always ask parents if they have concerns about development or behavior. In addition, the following should be observed:
chat.PDF
Toddler Development
Parent Development
Understands simple commands
Yes
No
Appropriately disciplines toddler
Yes
No
Walks well, stoops
Yes
No
Says 3 – 10 words
Yes
No
Positively talks, listens, and responds to
Yes
No
toddler
Indicates wants by pointing or gestures.
Yes
No
Is able to transition from one activity to
Yes
No
Parent is loving toward toddler
Yes
No
another throughout the day
Appears to have a secure and attached
Yes
No
Uses words to tell toddler what is coming
Yes
No
relationship with parent
next
Please note: Formal developmental examinations are recommended when surveillance suggests a delay or abnormality, especially when the opportunity for continuing
observation is not anticipated. (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents)
Additional Notes from pages 1 and 2:
Staff Signature: __________________________________________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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