Visit Documentation Forms: 6 Year Visit

Please correct the errors described below.

WELL CHILD: 6 YEAR VISIT

HISTORY

MEDICAL HISTORY

NUTRITION

Physical Activity

School

Performance

DEVELOPMENT

  • Cuts most foods with a knife
  • Ties shoes
  • Is dry day and night
  • Chooses preferred foods
  • Starts/continues conversations with peers
  • Plays and interacts with at least one “best friend”
  • Tells a story with a beginning, middle, and an end
  • Masters all consonant sounds and combinations, such as “d” or “ch”
  • Counts 10 objects
  • Can do simple addition and subtraction with objects
  • Rides a standard bike
  • Hops on one foot 3 to 4 times
  • Catches small ball with 2 hands
  • Draws a 12-part person
  • Prints 3 or more simple words without copying
  • Writes first and last names in uppercase or lowercase 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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