Visit Documentation Forms: 3 Year Visit

WELL CHILD: 3 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 no/in-process, please explain

Sleep

No concerns

Behavior

No concerns

Physical Activity

If no, please explain

Screen time

None

h/d

Source

DEVELOPMENT

Normal development

See Previsit Questionnaire.

If yes, please describe

SOCIAL LANGUAGE AND SELF-HELP

Goes to the bathroom and urinates by self
Plays and shares with others
Puts on coat, jacket, or shirt by self
Begins to play make-believe
Eats independently

VERBAL LANGUAGE

Uses 3-word sentences
Uses words that are 75% intelligible to strangers
Understands simple prepositions(eg, on, under)
Tells a story from a book or TV
Compares things using words such as bigger or shorter

GROSS MOTOR

Pedals tricycle
Climbs on and off couch or chair
Jumps forward

FINE MOTOR

Draws a single circle
Draws a person with head and one other body part
Cuts with child scissors

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

Parent-child interaction:

Communication

If checked, please explain

Cooperation

If checked, please explain

Choices

If checked, please explain

Appropriate responses to behavior

If checked, please explain

If yes, please specify type

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 interval growth. Normal BMI and BP for age.

Head: Normocephalic and atraumatic.

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

Ears, nose, mouth, and throat: Tympanic membranes with visible light reflex bilaterally. Healthy-appearing teeth without caries, plaque, discoloration, or breakage. No oral lesions or gingivitis.

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. Speech clear and appropriate language for age.

Skin: Warm and well perfused. No lesions (atypical nevi, café-au-lait spots, or birthmarks) or bruising.

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

Living situation and food security
Tobacco, alcohol, and drug use
Positive family interactions
Work-life balance

PLAYING WITH SIBLINGS AND PEERS

Play opportunities and interactive games
Sibling relationships

ENCOURAGING LITERACY ACTIVITIES

Reading, talking, and singing together
Language development

PROMOTING HEALTHY NUTRITION AND PHYSICAL ACTIVITY

Water, milk, and juice
Nutritious foods
Competence in motor skills and limitson inactivity

SAFETY

Car safety seats
Choking prevention
Pedestrian safety and falls from windows
Water safety
Pets
Gun safety

PLAN

(Immunizations) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Oral health

N/A

If no, please explain

Vision

If abnormal, please explain

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

Anemia

Hearing

Lead

Oral health

Tuberculosis

Comments/results

Follow-up

Routine follow-up at 4 years

Next visit

Referral to

Next visit

Referral to

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