Visit Documentation Forms: 4 Year Visit

WELL CHILD: 4 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 has bowel movement by self
Dresses and undresses without much help
Plays make-believe

VERBAL LANGUAGE

Uses 4-word sentences
Uses words that are 100% intelligible to strangers
Answers questions
Tells a story from a book

GROSS MOTOR

Climbs stairs, alternating feet without support
Skips on one foot

FINE MOTOR

Draws a person with at least 3 body parts
Draws a simple cross
Unbuttons and buttons medium-sized buttons
Grasps a pencil with thumb and fingers instead of fist
Draws recognizable pictures

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: 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 visible decay or white spots. No 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 fluent without articulation difficulties. 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

Living situation and food security
Tobacco, alcohol, and drug use
Intimate partner violence
Safety in the community
Engagement in the community

DEVELOPING HEALTHY NUTRITION AND PERSONAL HABITS

Water, milk, and juice
Nutritious foods
Daily routines that promote health

SCHOOL READINESS

Language understanding and fluency
Feelings
Opportunities to socialize with other children
Readiness for structured learning experiences
Early childhood programs and preschool

MEDIA USE

Limits on use
Promoting physical activity and safe play

SAFETY

Belt-positioning car booster seats
Outdoor safety
Water safety
Sun protection
Pets
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

Dyslipidemia

Lead

Oral health

Tuberculosis

Comments/results

Follow-up

Routine follow-up at 5 years

Next visit

Referral to

Next visit

Referral to

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