Visit Documentation Forms: 5 Year Visit

Please correct the errors described below.

WELL CHILD: 5 YEAR VISIT

HISTORY

MEDICAL HISTORY

NUTRITION

Physical Activity

School

Performance

DEVELOPMENT

  • Spreads with a knife
  • Dresses and undresses without help
  • Goes to bathroom independently
  • Is dry through the day
  • Plays and interacts with peers
  • Answers “why” questions
  • Tells a story of 2 sentences or more
  • Follows directions for 4 individual prepositions
  • Counts 5 objects
  • Names 3 or more numbers
  • Names 4 or more letters out of order
  • Is beginning to skip
  • Walks on tiptoes when asked
  • Catches a bounced ball with 2 hands
  • Copies a triangle
  • Draws a 6-part person
  • Copies first name
  • Cuts well with scissors
  • Writes 2 or more letters

SOCIAL AND FAMILY HISTORY

REVIEW OF SYSTEMS

Required Field = Focus area for this Bright Futures Visit

PHYSICAL EXAMINATION

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

Genitourinary

ASSESSMENT

ANTICIPATORY GUIDANCE

  • Neighborhood and family violence
  • Food security
  • Family substance use
  • Emotional security and self-esteem
  • Connectedness with family
  • Family rules and routines, concern for others, and respect for others
  • Patience and control over anger
  • Readiness, established routines,school attendance, and friends
  • After-school care and activities;parent-teacher communication
  • Oral health
  • Nutrition
  • Physical activity
  • Car safety
  • Outdoor safety
  • Water safety
  • Sun protection
  • Harm from adults
  • Home fire safety
  • Gun safety

PLAN

Universal Screening

Follow-up

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