Visit Documentation Forms: 18 Month Visit

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Visit Documentation Form: 18 Month Visit

HISTORY

Physical Activity

DEVELOPMENT

  • Engages with others for play
  • Helps dress and undress self
  • Points to pictures in book
  • Points to object of interest to draw attention to it
  • Turns and looks at adult if something new happens
  • Begins to scoop with spoon
  • Uses 6 to 10 words other than names
  • Identifies at least 2 body parts
  • Walks up with 2 feet per step with hand held
  • Sits in small chair
  • Carries toy while walking
  • Scribbles spontaneously
  • Throws small ball a few feet while standing

SOCIAL AND FAMILY HISTORY

REVIEW OF SYSTEMS

Required Field = Focus area for this Bright Futures Visit

PHYSICAL EXAMINATION

Required Field = Focus area for this Bright Futures Visit

Genitourinary:

ASSESSMENT

ANTICIPATORY GUIDANCE (Discussed and/or handout given )

  • Encouragement of language
  • Use of simple words and phrases
  • Engagement in reading, playing, talking, and singing
  • Promotion of reading
  • Physical activity and safe play
  • Anticipation of return to separation anxiety and managing behavior with consistent limits
  • Recognizing signs of toilet-training readiness and parental expectations
  • New sibling planned or on the way
  • Nutritious foods; water, milk, and juice
  • Expressing independence through food likes and dislikes
  • Car safety seats and parental use of seat belts
  • Poisoning
  • Sun protection
  • Gun safety
  • Safe home environment: burns, fires, and falls

PLAN

Universal Screening

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

Follow-up

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