General Pediatric Clinic/elementary School Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068K (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / ELEMENTARY SCHOOL VISIT
nd
(See 2
page for Anticipatory Guidance for Elementary School Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
BMI
Today’s Date
Accompanied by
BP
Urinalysis
Urine Culture
Pulse
Vision
R.
/
L.
/
Color
Hearing
Gross
Audiogram
Parental Concerns
Adjustment to Clinic Visit
Mood
Living Situation
Intensity to Reactions
Speech and Language
School and Grade: Adjustment
Dental Referral
Extracurricular Activities: Hobbies, Sports
Note – Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Part
N
Abn
Skin: Color, texture
Eating Habits
Head: Symmetry, scalp, hair
Eyes: OM, pupils, cornea, conjunctiviae
Ears: Pinnae, canals, tympanic membranes
Nose: Nares and turbinates
General Health
Mouth: Tongue, gums, number of teeth ( )
Throat: Pharynx, tonsils
Neck: Movements, thyroid
Nodes: Axillary cervical, inguinal, submandibular
Check: Expansion, breast tissue
Parents’ Description of child’s Temperament: Adjustments to Home,
Lungs:
Environment, Attention Span, Distractibility, Peer Relationships
Heart: Rhythm S1, S2, murmur
Abdomen: Contour, LSK mass
Genitourinary: Vagina, testes, urethral orifice, hernia
Neuromuscular: Equilibrium, motor strength, sensory,
Coordination, cranial nerves, DTRs, Babinski
Spine: Posture, hip and shoulder levels
Problems Identified and Reviewed
Extremities: Gait, range of motion of joints
Anus: Rectal
Sexual Development: (Describe)
Physical and Emotional Status
Describe abnormal findings.
Obs = Observed
M = Mother
Parents Interactions with Child
F = Father
NO* = Not observed here
Diet
Activity
Obs
NO*
Makes eye contact
Anticipatory Guidance: Consistency of approach, guidance, need for
Touches child
praise, independence, allowance, modeling of behavior, responsibilities
Hovers over child
and role in family, honesty and ownership, fears and fantasies, television.
Spontaneously identifies positive qualities
School responsibilities, punctuality, home work, sex education, literature
Reassures child who is unsure of situation
for parents and child.
Limits activity by verbal command
Safety: Cars, bikes, guns, water.
Limits activity by physical command
Dental Care:
Voice calm when talking to child
SIGNATURE — Provider
Date Signed
Gives simple, short directions/explanations
Reinforces through approval and attention
Terminates activity with some forewarning
Allows child to answer for self
Return to clinic in _____ months.
Interrupts child’s conversation
Limits child’s exuberance
Other Observations
Development and Parent-Child Interactions
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