Visit Documentation Forms: 9 Months Visit

WELL CHILD: 9 MONTHS VISIT

Name

ID number

Date of Birth

Age

Accompanied By

Preferred Language

Date/Time

Weight (%)

Length (%)

Weight-for-length (%)

HC (%)

Vitals (if indicated): Temp

Resp Rates

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.)

Current Medications

Allergies

NUTRITION

Breastmilk

Formula

Add Information (Breastmilk)

Add Information (Formula)

Solids

Elimination

Regular Soft Foods

Sleep

Normal Pattern

Safe Sleep Surface

Behavior

Physical Activity

Playtime (60 min/d)

Yes

If no, please describe

Screen Time

Yes

Development

Normal development

See Previsit Questionnaire

If yes, please explain

SOCIAL LANGUAGE AND SELF-HELP

Uses basic gestures (eg, holds arms out to be picked up, waves “bye-bye”)
Looks for dropped objects
Picks up food with fingers and eats it
Turns when name called

GROSS MOTOR

Sits well without support
Pulls to stand
Transitions between sitting and lying
Balances on hands and knees
Crawls

FINE MOTOR

Picks up small object with 3 fingers and thumb
Releases objects intentionally
Bangs objects together

VERBAL LANGUAGE

Says “Dada” or “Mama” nonspecifically

SOCIAL AND FAMILY HISTORY

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

Social History

Family History

Changes since last visit

Smoking household

Yes

If yes, please explain

Parental support and work-family balance

Observation of parent-infant interaction

If other, please specify

REVIEW OF SYSTEMS

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

Required = 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

Required = Focus area for this Bright Futures Visit

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.

Eyes: Fixes and follows. Extraocular eye movements intact. Red reflex present bilaterally. No opacification. Normal funduscopic examination findings.

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

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

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.

Genitourinary

Normal female external genitalia

Normal male external genitalia, with testes palpable in scrotum bilaterally.

Musculoskeletal: Spine straight. Normal hip abduction.

Neurological: Moves all extremities symmetrically. Normal strength and tone. Parachute reflex present.

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

Discussed and/or handout given

SOCIAL DETERMINANTS OF HEALTH

Intimate partner violence
Family relationships and support

NUTRITION AND FEEDING

Self-feeding
Mealtime routines
Transition to solid foods
Cup drinking
Plans for weaning

INFANT BEHAVIOR AND DEVELOPMENT

Changing sleep patterns
Developmental mobility and cognitive development
Interactive learning and communication
Media

DISCIPLINE

Parent expectation of infant’s behavior

SAFETY

Car safety seats
Heatstroke prevention
Firearm safety
Safe home environment: burns, poisoning, drowning, and falls

PLAN

(Immunization) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Developmental screening

Screening tool used

If following areas is selected, please specify

Oral health risk assessment

Fluoride varnish applied

Yes

If no, please explain

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

Hearing

Lead

Oral fluoride supplementation

Vision

Comments/results

Follow-up

Routine follow-up at 12 months

Next visit

Referral to

Next Visit

Referral to

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