Health assessment of the Preschool Child Worksheet (12 months - 4 years)

The 12 Month to 4 Years Worksheet

The preschool child health maintenance worksheet, (12 months to 4 years) is available on the sidebar. Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.

 

Interim History since last well child visit:

 

Concerns to discuss today:

OLD CARTS, present history in logical, chronological order

 

Review Past Medical History/Family Medical History (PMH/FMH):

Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives

 

Medications:

Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies

 

Allergies:

Include drug, food, and environmental allergies and patient's reaction

 

Social History:

Include who lives at home, who cares for the child/daycare, smoke exposure, pets

 

Nutritional Assessment:

 

Breastfeeding ___min every ___hour.
Mother's assessment of milk production:___________

milk________oz every _____ hrs (bottle/cups) 

 

Other liquids (water/juice)

Other foods/ Appetite/Schedule
Wet diapers per day

Stools per day

Parent concerns regarding nutrition or output

 

Mental Health Assessment:

Include: Tantrums, Behavior challenges, Sleep problems, New family stresses, Parenting needs, Child abuse risk

 

Developmental Assessment:/Ages and Stages Questionnaire/MCHAT(18 to 24 months):

List milestones achieved: gross motor/fine motor/language/personal-social

Review of Systems:
Physical Exam:

 

Vital Signs:

Weight (percentile):_______,____%
Length(percentile):_______,____%

BMI: :_______,____%

Temperature:_________
Pulse:__________
Respiratory rate:________
Blood pressure:_________

 

General appearance
Head
Eyes
Ears
Nose
Mouth and Teeth

Oropharynx
Neck/nodes
Respiratory

Cardiovascular

Abdominal

Genitalia

Musculoskeletal/hips
Neurologic/reflexes

Skin

Other

Screening:

Vision, Hearing, Hemoglobin, Tuberculosis questionnaire, Dental screening/varnish,

 

Health Education/Anticipatory Guidance:

Nutrition: Milk and Juice, Advancing diet, Growth charts

Safety: Bath, Hot water temperature, Smoke detectors, Car seats, Childproofing, Ingestions, Choking, Walkers/jumpers, Firearms

Health Promotion: Immunizations,Tobacco exposure, Med. Resource Use, Limit screen time, Monitor screen content

Family: Siblings, Address concerns

Immunizations indicated today:

Labs (hemoglobin/lead/other)/procedures (dental varnish) indicated today:

Based on screening and Texas Health Steps Recommendations

Next Well Check :

 


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