Visit Documentation Forms: 15 Month Visit

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Visit Documentation Form: 15 Month Visit

HISTORY

Physical Activity

DEVELOPMENT

  • Imitates scribbling
  • Drinks from cup with little spilling
  • Points to ask for something or to get help
  • Uses 3 words other than names
  • Speaks in sounds that seem like an unknown language
  • Follows directions that do not include a gesture
  • Looks around when parent says, “Where is…?”
  • Squats to pick up objects
  • Crawls up a few steps
  • Begins to run
  • Makes mark with crayon
  • Drops object into and takes object out of container

SOCIAL AND FAMILY HISTORY

REVIEW OF SYSTEMS

Required Field = Focus area for this Bright Futures Visit

PHYSICAL EXAMINATION

Required Field = Focus area for this Bright Futures Visit

Genitourinary:

ASSESSMENT

ANTICIPATORY GUIDANCE (Discussed and/or handout given )

  • Individuation
  • Separation
  • Finding support
  • Attention to how child communicates wants and interests
  • Regular bedtime routine
  • Night waking
  • No bottle in bed
  • Brushing teeth
  • Reducing caries
  • Car safety seats and parental use of seat belts
  • Safe home environment: poisoning, falls, and fire safety
  • Conflict predictors and distraction
  • Discipline and behavior management

PLAN

Universal Screening

Selective Screening (based on risk assessment) (See Previsit Questionnaire.):

Follow-up

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