health maintenance exam samples

Tagged as: fillable, health-maintenance, note-template

Subjective/History
1 week history
#1 Health maintenance Has done well since hospital discharge. ***Nursing/--- formula*** every 1-3 hours. Growth is normal. Alert to sights and sounds. No problems with urine or stool. Quiets with comforting. Sleeps on back. Newborn screen ***pending/negative/---***. All other systems are negative.
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2 month history
#1 Health maintenance Has done well over the past month. Nutrition includes ***feeding/nursing every 2-3 hours/--- formula every 2-3 hours***. Growth is normal. Alert to sights and sounds. Coos and smiles. Turns to sound. Holds object. Recognizes face. No concerns regarding hearing. No problems with urine or stool. Sleeps on back. Usual sleep pattern. All other systems are negative.
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4 month history
#1 Health maintenance Has done well over the past two months. Nutrition includes ***nursing/--- formula***. Growth is normal. Speech includes squealing and cooing. No concerns regarding hearing. Responsive. Smiling. Reaches for objects. Hands to midline/mouth. Head up prone. Pivots while on stomach. No problems with urine or stool. Usual sleep pattern. All other systems are negative.
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6 month history
#1 Health maintenance Has done well over the past two months. Nutrition includes ***--- formula/nursing*** plus solids. Growth is normal. Speech includes squealing, cooing, and some repetitive sounds. No concerns regarding hearing. Motor skills include rolling, sitting, and transferring with both hands. Looks for object. Toes to mouth. No problems with urine or stool. No significant sleep issues. No previous immunization reactions. All other systems are negative.
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9 month history
#1 Health maintenance Has done well over the past few months. Nutrition includes ***formula feeding with ---/nursing*** along with baby and table foods. Growth is normal. Speech includes repetitive sounds and conversational babble. No concerns regarding hearing. Motor skills include pulling to a stand, cruising furniture, and use of pincer grasp. Waves bye-bye. No problems with urine or stool. Some night awakening and stranger anxiety. All other systems are negative.
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15 month history
#1 Health maintenance Has done well over the past few months. Nutrition includes table foods along with whole milk and occasional juice. Growth is normal. Speech includes a few words and conversational babble. No concerns regarding hearing. Motor skills include walking, running, using a spoon, scribbling. No problems with urine or stool. Temperament is moderate, for which parents use simple choice. No significant sleep issues. All other systems are negative.
2 year history
#1 Health maintenance Has been generally healthy over the past few months. Nutrition includes milk and a variety of foods. ***Vitamins/Fluoride***. Growth is normal. Speech includes two to three word sentences that are more than half intelligible. Follows instructions. No concerns regarding hearing. Motor skills include running, kicking a ball, climbing steps, attempts at dressing, use of a spoon and fork and social interactions. Temperament is moderate. Parents use simple choice and time-out with good effect. There is some interest in toileting but little initiative. No significant sleep issues. No significant reaction to previous immunizations. No lead risk/Not exposed to housing 1950 or older. No TB risk/exposure to TB is unlikely. Neither parent with cholesterol > 300. All other systems are negative.
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3 year history
#1 Health maintenance Has been generally healthy over the past few months. Nutrition includes milk and a variety of foods. ***Vitamins/Fluoride*** Growth is normal. Speech includes three to four word sentences that are more than 3/4 intelligible. Motor skills include throwing a ball overhand, building a six-cube tower, washing and drying hands, dressing and undressing, walking up and down steps, cutting with scissors, and interest in toileting. Parents use simple choice and time-out with good effect. No significant sleep issues. Social interactions are fine. No significant reaction to previous immunizations. No lead risk/Not exposed to housing 1950 or older. No TB risk/exposure to TB is unlikely. Neither parent with cholesterol > 300. All other systems are negative.
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4 year history
#1 Health maintenance Has been generally healthy over the past year. Nutrition includes milk and a variety of foods. Growth is normal. Speech includes full sentences that are more than 3/4 intelligible. Identifies colors and shapes. Motor skills include dressing and undressing, toileting, hopping on one foot. Social interactions are fine. Plays with other children. Parents use simple choice and time-out with good effect. All other systems are negative.
5 year history
#1 Health maintenance Has been generally healthy over the past year. Nutrition includes milk and a variety of foods. Growth is normal. Speech and motor skills are normal for age. Dresses without supervision, draws person, defines 5/8 ball, lake, desk, house, banana, curtain, fence, ceiling, and balances on each foot four seconds. No concerns regarding school readiness. No problems with toileting. Social interactions are fine. Discussed anger style. Behavior approach includes time-out and simple choices. No previous reaction to immunizations. No lead exposure risk. All other systems are negative.
6-10 year history
#1 Health maintenance Has been generally healthy over the past year. Nutrition includes a variety of foods and good milk intake. Growth is normal. Exercise is regular. No height/weight concerns. No school performance or social interaction concerns. Discussed anger style, moods. Typical dependence issues with choice and time-out/privileges approach. No problems with urine or stool. Denies smoking. All other systems are negative.
11-14 year history
#1 Health maintenance Has been generally healthy over the past year. Nutrition includes a variety of foods and good milk intake. Growth is normal. Exercise is regular. No height/weight concerns. No school performance or social interaction concerns. Discussed anger style, moods, etc. Typical independence issues with choice and privileges approach. No problems with urine or stool. Denies sexual activity, smoking, alcohol or other drug use. All other systems are negative.
15-18 year history
#1 Health maintenance Has been generally healthy over the past year. Nutrition includes a variety of foods and good milk intake. Growth is normal. Exercise is regular. No height/weight concerns. Education and work plans ***. Denies depression/anhedonia. No problems with urine or stool. Denies sexual activity, smoking, alcohol or other drug use. All other systems are negative.
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Objective/Examination
Newborn male
Skin: Normal turgor and without lesions. Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light Head: Normocephalic with age appropriate fontanelles. Peripheral Vessels: Normal pulses and perfusion. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds. Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention. Genitalia: Normal male external genitalia. Testes descended bilaterally. No hernia present. Spine: Straight with no lesions. Joints: Hips with full range-of-motion; negative Barlow and Ortolani. Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
Newborn female
Skin: Normal turgor and without lesions. Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light Head: Normocephalic with age appropriate fontanelles. Peripheral Vessels: Normal pulses and perfusion. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds. Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention. Genitalia: Normal female external genitalia. No hernia present. Spine: Straight with no lesions. Joints: Hips with full range-of-motion; negative Barlow and Ortolani. Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
<1 year male
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic with age appropriate fontanelles. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
<1 year female
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic with age appropriate fontanelles. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal female external genitalia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
1-4 year male
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
1-4 year female
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal female external genitalia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
>4 year male
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
>4 year female
General: Child appears age appropriate. Vitals noted and stable. Skin: Normal turgor and without lesions. Head: Normocephalic. Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi. ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. Lymph Nodes: No significant lymphadenopathy. Thyroid: No thyromegaly; trachea midline without masses. Breasts: Without lesions or drainage. Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Extremities are warm and well perfused and capillary refill is less than 2 seconds. Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. Genitalia: Normal female external genitalia. Spine: Straight with no lesions. Joints: Full range of motion about all joints. Extremities: Digits and nails are normal Gait: Normal and appropriate gait for age. Mental Status: Alert, oriented, in no distress. Appropriate for age. Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age.
Assessment/Plan
1 week plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. Age specific guidance: infant should sleep on back, pets (keep separated from child), use of car restraints, do not leave near water or where child can fall, assure water heater temp. set <120 degrees and test fire alarms. ***No immunizations/Hepatitis B*** given today. Side effects, risks, and benefits of immunizations discussed. Return to clinic at 2 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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2 month plan
#1 Normal growth and development Age specific guidance: infant should sleep on back, use car restraints, do not leave the child near water or where the child can fall, do not use walkers or small toys and burn prevention reviewed. Immunizations today: ***HBV-Hib, DTaP, and IPV (Hepatitis B-Haemophilus influenza, Diphtheria-Tetanus-acellular Pertussis and polio), PCV7 (Pneumococcal), Rota. Side effects, risks, and benefits of immunizations discussed.*** Return to clinic at 4 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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4 month plan
#1 Normal growth and development Age specific guidance: use car restraints, do not leave near water or where the child can fall, do not use walkers or small toys, avoidance of plastic's suffocation and burn prevention reviewed. A/B Otic drops prescription and discussion about how to use as needed Immunizations today: ***Hib, DTaP, and IPV (Hepatitis B- Haemophilus influenza, Diphtheria-Tetanus, acellular Pertussis and polio), PCV7 (Pneumococcal), Rotavirus***. Side effects, risks, and benefits of immunizations discussed. Return to clinic at 6 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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6 month plan
#1 Health Maintenance-Normal Growth and Development Age specific guidance: use of car restraints, supervise around water or where the child can fall, use gates to block stairway, be careful of cords and plants, do not use walkers or allow with small objects, burn prevention reviewed. Side effects, risks and benefits of immunizations Immunizations today: ***DTaP (Diphtheria-Tetanus-acellular Pertussis)/HBV (hepatitis)/PCV7 (Pneumococcal)/ROTA (Rotavirus)*** Return appointment: ***age nine months/age twelve months/age fifteen months*** or sooner if needed.
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9 month plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. ***No immunizations given today/Immunizations given today***. Side effects, risks, and benefits of immunizations discussed. Return to clinic at 15 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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15 month plan
#1 Health Maintenance-Normal Growth and Development Age specific guidance: choking, use of gates, caution around open water, falling, sunscreen if summer, smoke detectors, smoke free environment, lower crib mattress, check window guards, supervise near dogs and lawnmowers and streets and driveways, burn prevention, and tantrum information reviewed. Recommended to eat meals as family, allow toddler to feed self and drink from cup not bottle, 2 snacks low in sugar daily, avoid choke foods, don't put toddler to bed with bottle, brush teeth daily, fluoride discussed. Give individual attention, limit but enforce rules, allow no harm to self or things or others, delay toilet training. Side effects, risks and benefits of immunizations discussed. Poison prevention discussed -- Keep potential poisons out of sight and out of reach. Always reengage child-resistant closures immediately after using a pharmaceutical or consumer product. Never transfer a substance from its original container to an alternate one. Safely dispose of all unused medication and medication that is no longer needed. Do not refer to medicines as candy. Post the poison control center number near the telephone. The universal telephone number in the United States is 800-222-1222. Calls are routed to the local poison control center. Tuberculosis Risk (Close contact with person with TB, live in area where TB is common, recent immigrant?): ***No/Yes, testing recommended*** Immunizations today: ***DTaP/Hib/PCV7/Influenza vaccine/HAV*** Return appointment: ***age two years/age 18 month visit with doctor/age 18 month visit with nurse for immunizations*** or sooner if needed.
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2 year plan
#1 Normal growth and development Age specific guidance: Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, toilet training, night terrors and tantrum information reviewed. ***No immunizations given today/Influenza/Hepatitis A/Side effects, risks, and benefits of immunizations discussed.*** Return to clinic at 3 years of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Testing ***is/not*** indicated for TB (exposure to patient with TB, recent immigrant, area with high TB prevalence). Testing ***is/not*** indicated for lead (house older than 1950). Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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3 year plan
#1 Normal growth and development Age specific guidance: Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, use of bike helmet, toilet training, night terrors and tantrum information reviewed. ***No immunizations given today/Immunizations given today/MMR (Measles-Mumps-Rubella)/Side effects, risks, and benefits of immunizations discussed.*** Vision screening: ***assessed/not assessed/child uncooperative***. Hearing screening: ***assessed/not assessed/child uncooperative***. Testing ***is/not*** indicated for TB (exposure to patient with TB, recent immigrant, area with high TB prevalence). Testing ***is/not*** indicated for lead (house older than 1950). Return to clinic at 5 years of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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4 year plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. ***No immunizations given today/Immunizations given today***. Side effects, risks, and benefits of immunizations discussed. Return to clinic in two years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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5 year plan
#1 Health Maintenance-Normal Growth and Development Age specific guidance: Burn prevention (matches), care near streets, caution around open water, use of seatbelt information reviewed, self-esteem issues, limit television time, use of helmets when riding bike or scooter Immunizations today: ***None/DTaP/MMRV/IPV/Flu/Hep A***. Side effects, risks and benefits of immunizations. Vision screening: ***assessed/not assessed/child uncooperative*** Hearing screening: ***assessed/not assessed/child uncooperative*** Return appointment: ***age 7 yrs/age 9 yrs*** or sooner if needed.
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6-10 year plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. ***No immunizations given today/Immunizations given today***. Side effects, risks, and benefits of immunizations discussed. Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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11-14 year plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. ***Immunizations given/No immunizations given today*** Side effects, risks, and benefits of immunizations discussed. Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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15-18 year plan
#1 Normal growth and development Injury prevention and health promotion issues discussed. ***Immunizations given. Side effects, risks, and benefits of immunizations discussed/No immunizations given today***. Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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