Well Child Exam Form - Infancy: 2 Months
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WELL CHILD EXAM-INFANCY: 2 Months
DATE
PATIENT NAME
DOB
SEX
PARENT/GUARDIAN NAME
Allergies
Current Medications
Prenatal/Family History
Weight
Percentile
Length
Percentile
HC
Percentile
Temp.
Pulse
Resp.
BP (if risk)
%
%
%
Anticipatory Guidance/Health Education
□ Vaginal □ C-Section
Birth History
(√ if discussed)
Birth Wt.: _________ Gestation: ____________
Complications □ Y □ N
Interval History:
Safety
Patient Unclothed
□ Y
□ N
□ Appropriate car seat placed in back seat
(Include injury/illness, visits to other health
Review of
Physical
□ Keep home and car smoke-free
care providers, changes in family or home)
Systems
Exam
Systems
□ Keep hot liquids away from baby
N
A
N
A
□ Don’t leave baby alone in tub or high
General
□
□
□
□
places; always keep hand on baby
Appearance
□ Water temp. <120 degrees/test with wrist
□
□
□
□
Apnea □ Y □ N □ Monitor
Skin/nodes
□ Never shake baby
Nutrition
□
□
□
□
Head/fontanel
□ Breast every ______ hours
Nutrition
□ Hold baby when feeding
□ Formula ____ oz every _____ hours
□
□
□
□
Eyes
□ Breast on demand or feed iron-fortified
With iron □ Y □ N
formula
Type or brand
□
□
□
□
Ears
□ Delay solid foods until 4-6 months
_____________________________
□
□
□
□
Nose
□ City water
□ Well water
Infant Development
Elimination
□ Put baby to sleep on back/Safe Sleep
□
□
□
□
Oropharynx
□ Normal
□ Abnormal
□ Learn baby’s temperament/responses
Sleep
□
□
□
□
□ Console, hold, cuddle, rock, play with
Gums/palate
□ Normal (2-4 hours)
□ Abnormal
baby
□
□
□
□
Additional area for comments on page 2
Neck
□ Talk, sing, play music, and read to baby
WIC
□ Tummy time while awake
□
□
□
□
Lungs
□ Y □ N
□ Consistent feeding/sleep routines
□ Strategies to deal with fussy periods
Maternal Infant Health Program
□
□
□
□
Heart/pulses
□ Y □ N
Family Adjustment
□
□
□
□
Abdomen
□ Encourage partner and other children (as
Screening and Procedures:
appropriate) to help care for infant
□
□
□
□
Genitalia
Neonatal Metabolic Screen in Chart
□ Keep in contact with friends, family
□ Y □ N Test Date: _______
□ Substance Abuse, Child Abuse, Domestic
□
□
□
□
Spine
□ Normal □ Pending
□ Today
Violence Prevention
□ Subjective Hearing -Parental observation/
□
□
□
□
□ Discuss child care, returning to work,
Extremities/hips
concerns
play group
□
□
□
□
□ Subjective Vision -Parental observation/
Neurological
concerns
Parental Well Being
□ Abnormal Findings and Comments
□ Family Planning
Developmental Surveillance
If yes, see additional note area on next page
□ Take time for self and spend time alone
□ Social-Emotional □ Communicative
Results of visit discussed with parent □ Y □ N
with your partner
□ Cognitive □ Physical Development
Psychosocial/Behavioral Assessment
Plan
Other Anticipatory Guidance Discussed:
□ Y □ N
□ History/Problem List/Meds Updated
□ Y □ N
Screening for Abuse
□ Referrals
□ WIC
□ Early On
□ Transportation
Immunizations:
®
□ Immunizations Reviewed
□ Maternal Infant Health Program (MIHP)
Next Well Check: 4 months of age
□ Immunizations Given & Charted – if not
□ Children Special Health Care Needs
Developmental Surveillance on Page 2
given, document rationale
□ Other referral_________________
Page 3 required for Foster Care Children
□ DTaP □ IPV □ HepB □ Hib □ PCV
Provider Signature:
□ Other ________________________________
□Rota
□ MCIR checked/updated
□ Acetaminophen ____ mg. q. 4 hours
PAGE 1
Updated 4/2011
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