Visit Documentation Forms: 5 Year Visit

WELL CHILD: 5 YEAR VISIT

Name

ID number

Birth Date

Age

Accompanied By

Preferred Language

Date/Time

Weight (%)

Height (%)

BMI (%)

BP (%)

Vitals (if indicated): Temp

Resp Rate

SPO2

HISTORY

Concerns and Questions

None

Interval History

None

MEDICAL HISTORY

Child 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

None

Reviewed and updated (See Medication Record.)

Allergies

No known drug allergies

NUTRITION

Good appetite

Good variety

Daily fruits and vegetables

Iron source

Calcium

Source

Amount

If yes, please specify

Comments

If yes, please describe

If no, please explain

If other, please specify

Elimination

Regular soft stools

If checked, please explain

Sleep

No concerns

Physical Activity

If no, please explain

Screen time

None

h/d

Source

School

Grade

Performance

If checked, please explain

Parent/teacher concerns

None

Behavior

No concerns

DEVELOPMENT

Normal development

See Previsit Questionnaire.

If yes, please describe

SOCIAL LANGUAGE AND SELF-HELP

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

VERBAL LANGUAGE

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

GROSS MOTOR

Is beginning to skip
Walks on tiptoes when asked
Catches a bounced ball with 2 hands

FINE MOTOR

Copies a triangle
Draws a 6-part person
Copies first name
Cuts well with scissors
Writes 2 or more letters

SOCIAL AND FAMILY HISTORY

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

Social History

Family History

Changes since last visit

No interval change

If yes, please explain

Observation of parent-child interaction

After-school care

REVIEW OF SYSTEMS

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

Required Field = Focus area for this Bright Futures Visit

Constitutional

Respiratory

Skin

Eyes

Gastrointestinal

Neurological

Head, Ears, Nose, and Throat

Genitourinary

Other

Cardiovascular

Musculoskeletal

Other

PHYSICAL EXAMINATION

System examined

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

General: Well-appearing child. Normal BMI and BP for age.

Head: Normocephalic and atraumatic.

Eyes: Pupils equal, round, and reactive to light. Extraocular eye movements intact. Normal funduscopic examination findings.

Ears, nose, mouth, and throat: Tympanic membranes with visible light reflex bilaterally. Healthy-appearing teeth without visible caries. No gingivitis. No malocclusion.

Neck: Supple, with full range of motion and no significant adenopathy.

Heart: Regular rate and rhythm. No murmur.

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing.

Abdomen: Soft, with no palpable masses.

Genitourinary

Normal female external genitalia.

Normal male external genitalia, with testes descended bilaterally.

Musculoskeletal: Spine straight. Full range of motion.

Neurological: Normal gait. Fine motor skills appropriate for age.

Skin: Warm and well perfused. No rashes or bruising. No atypical nevi or birthmarks.

Other comments:

ASSESSMENT

Well child

Normal interval growth (See growth chart.)

Normal BMI percentile for age

Normal BP percentile for age

Age-appropriate development

ANTICIPATORY GUIDANCE

Discussed and/or handout given

SOCIAL DETERMINANTS OF HEALTH

Neighborhood and family violence
Food security
Family substance use
Emotional security and self-esteem
Connectedness with family

DEVELOPMENT AND MENTAL HEALTH

Family rules and routines, concern for others, and respect for others
Patience and control over anger

SCHOOL

Readiness, established routines,school attendance, and friends
After-school care and activities;parent-teacher communication

PHYSICAL GROWTH AND DEVELOPMENT

Oral health
Nutrition
Physical activity

SAFETY

Car safety
Outdoor safety
Water safety
Sun protection
Harm from adults
Home fire safety
Gun safety

PLAN

(Immunizations) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Hearing

If abnormal, please explain

Vision

If abnormal, please explain

Oral health

N/A

If no, please explain

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

Anemia

Lead

Oral health

Tuberculosis

Comments/results

Follow-up

Routine follow-up at 6 years

Next visit

Referral to

Next visit

Referral to

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