Visit Documentation Forms: 1 Month Visit

WELL CHILD: 1 MONTH VISIT

Name

ID number

Date of Birth

Age

Appointment By

Preferred Language

Date/Time

Weight (%)

Length (%)

Weight-for-length (%)

HC (%)

Vitals (if indicated): Temp

Resp Rate

SPO2

HISTORY

Concerns and Questions

Interval History

MEDICAL HISTORY

Infant has special health care needs.

Areas reviewed and updated as needed

Past Medical History (See Initial History Questionnaire.)

Surgical History (See Initial History Questionnaire.)

Problem List (See Problem List.)

Medications

Reviewed and updated (See Medication Record.)

Allergies

SCREENING RESULTS

Newborn blood screening

Normal

Abnormal

Newborn hearing screening

Passed BL

Referred By

NUTRITION

Breast Milk

Formula

Repeater 1 (Breast Milk)

Repeater 1 (Formula)

Elimination

Regular soft stools

Normal urine stream

Elimination

Regular soft stools

Normal urine stream

Sleep

Normal pattern

On Back

Safe sleep surface

Behavior

Activity (tummy time)

DEVELOPMENT

Caregiver concerns about development (Leave field if none)

SOCIAL LANGUAGE AND SELF-HELP

Calms when picked up or spoken to
Looks briefly at objects

VERBAL LANGUAGE

Alerts to unexpected sound
Makes brief short vowel sounds

FINE MOTOR

Holds fingers more open at rest

GROSS MOTOR

Holds chin up in prone

Areas reviewed and updated as needed (See Initial History Questionnaire.)

Social History

Family History

Changes since last visit

Smoking household

Parent adjustment to new infant

Observation of parent-infant interaction

Reactions of sibling to new infant

Work plans

Child care

Parent(s)

Family

In-home

Center

Other

If other, Specify

REVIEW OF SYSTEMS

A 10-point review of systems was performed and results were negative except for any positive results listed below

Constitutional

Respiratory

Skin

Eyes

Gastrointestinal

Neurological

Head, Ears, Nose, and Throat

Genitourinary

Other

Cardiovascular

Musculoskeletal

Other

PHYSICAL EXAMINATION

Normal examination findings in text. Cross out abnormalities. Describe other findings in the area provided.

General: Alert, active infant. Normal interval growth in height, weight, and head circumference. Normal weight-for-length for age

Head: Normocephalic and atraumatic. No positional skull deformities. Anterior fontanelle open and flat

Eyes: Normal eyes and eyelids. Fixes and follows. Red reflex present bilaterally. No opacification. Normal funduscopic examination findings.

Ears, nose, and throat: Tympanic membranes with visible light reflex bilaterally. No oral lesions or thrush.

Neck: Supple, with full range of motion without torticollis.

Heart: Regular rate and rhythm. No murmur. Symmetrical femoral pulses

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing

Abdomen: Soft, with no palpable masses. Well-healed umbilicus

Genitourinary

Normal female external genitalia

Normal male external genitalia, with testes palpable in scrotum bilaterally

Musculoskeletal: Spine straight. Negative Ortolani and Barlow maneuvers.

Neurological: Moves all extremities symmetrically. Normal posture and tone. Normal infant reflexes. Attends to visual and auditory stimulation.

Skin: Warm and well perfused. No lesions, birthmarks, or bruising

Other comments

ASSESSMENT

Well child

Normal interval growth (See growth chart.)

Age-appropriate development

ANTICIPATORY GUIDANCE

SOCIAL DETERMINANTS OF HEALTH

Living situation and food security
Environmental tobacco exposure
Dampness and mold, radon, and pesticides
Intimate partner violence
Maternal alcohol and substance use
Family support

INFANT BEHAVIOR AND DEVELOPMENT

Sleeping and waking
Fussiness and attachment
Media
Playtime
Medical home after-hours support

NUTRITION AND FEEDING

Feeding plans and choices
General guidance on feeding
Breastfeeding or formula-feeding guidance

PARENT AND FAMILY HEALTH

Postpartum checkup
Maternal depression
Family relationships

SAFETY

Car safety seats
Safe sleep
Emergency care

PLAN

Immunizations

Vaccine Administration Record reviewed

Up-to-date for age

Administered today

Maternal depression

Screening tool used

If yes, Please explain

Newborn blood screening

If Needs follow up, Please indicate

Newborn hearing screening:

If Needs follow up, Please indicate

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

Tuberculosis

Vision

Comments/results

Follow-up

Routine follow-up at 2 months

Next visit

Referral to

Next visit

Referral to

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