General Pediatric Clinic / 15 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068G (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 15 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 15 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Activity
Adaptability to Exam
Words Spoken
Rating Habits: __________________________ oz. / day
Note – Present (+) or Absent (-) as Appropriate
Diet
(Cross off parts not examined or not applicable)
Part
N
Abn
Behavior at Meals
Skin: Color, texture, hair, scalp
Head & face: Symmetry, AF size _____ cms _____
Eyes: Pupils, conjunctive, EOM, red reflex
Sleeping
Ears & nose: Canals, tympanic membranes, turbinates
Nose: Discharge
Activities: Quiet and Active
Mouth: Gums, Tongue, # of teeth
Nodes: Cervical, Inguinal
Lungs
Heart: Rhythm, S1, S2, murmur
Parents’ Description of Child’s Temperament
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Extremities: Range of motion, stance
Neuromuscular: Tone strength, equilibrium, coordination, Gait,
Problems Identified and Reviewed
DTRs
Describe abnormal findings.
Physical and Emotional Status
Diet: Pickiness, introducing new foods
R = Reported
O = Observed
Development Observation
R
O
NO*
NO* = not observed by parents or examiners
G.M. Walks
alone
Anticipatory Guidance: Obedience, negativism, temper,
Stoops and recovers
Tantrums. Sibling rivalry. Expectations on toilet training and speech.
Walks backwards
Safety: Climbing, stove, water, poisons, plants, street, lead exposure
Walks up steps with help
P.M.
Scribbles with a pencil
Makes a tower of two cubes
Lang.
Mama & Dada clear & appropriate
Immunization
Drug Co. and Lot No.
Expiration Date
2 + other single words
Points to a named part of the body
P.S.
Removes a piece of clothing
Drinks from a cup alone
SIGNATURE — Provider
Date Signed
Uses spoon with spilling
Explores by touching new objects
Comforted by physical contact with parents
Parents’ Interactions with Child O = Observed
M = Mother
Return to clinic in _____ months.
O
NO*
F= Father
NO* = Not observed here
Hovers over child
Spontaneously identifies positive qualities
Consoles child when showing reservations of strangers
Limits activity by verbal command
Limits activity by physical restraint
Gives simple, short directions/explanations
Ignores temper tantrum
Allows child to separate and check back
Other Observations
Development and Parent-Child Interaction
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