Health Maintenance Visit

Pediatrics, Complete Note, Featured
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[select name="Q1" value="1 week|2 month|4 month|6 month|9 month|12 month|15 month|2 year|3 year|4 year|5 year|6-10 year|11-14 year|15-18 year"] <-- Age
[select name="Q2" value="female|male"] <-- Gender
SUBJECTIVE/HISTORY:
[conditional field="Q1" condition="(Q1).is('1 week')"]
[text size=80 default="Has done well since hospital discharge. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="Alert to sights and sounds. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Quiets with comforting. "]
[text size=80 default="Sleeps on back. "]
[text size=80 default="Newborn screen pending/negative/***. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('2 month')"]
[text size=80 default="Has done well over the past month. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Sleeps on back. "]
[text size=80 default="Usual sleep pattern. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('4 month')"]
[text size=80 default="Has done well over the past two months. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Sleeps on back. "]
[text size=80 default="Usual sleep pattern. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('6 month')"]
[text size=80 default="Has done well over the past two months. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="No significant sleep issues. "]
[text size=80 default="No previous immunization reactions. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('9 month')"]
[text size=80 default="Has done well over the past few months. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="Speech includes repetitive sounds and conversational babble. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Some night awakening and stranger anxiety. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('12 month')"]
[text size=80 default="Has done well over the past few months. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="No significant sleep issues. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('15 month')"]
[text size=80 default="Has done well over the past few months. "]
[text size=80 default="Nutrition includes table foods along with whole milk and occasional juice. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="No significant sleep issues. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('2 year')"]
[text size=80 default="Has been generally healthy over the past few months. "]
[text size=80 default="Nutrition includes milk and a variety of foods. "]
[text size=80 default="Vitamins/Fluoride. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding hearing. "]
[text size=80 default="No significant sleep issues. "]
[text size=80 default="No significant reaction to previous immunizations. "]
[text size=80 default="No lead risk/Not exposed to housing 1950 or older. "]
[text size=80 default="No TB risk/exposure to TB is unlikely. "]
[text size=80 default="Neither parent with cholesterol greater than 300. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('3 year')"]
[text size=80 default="Has been generally healthy over the past few months. "]
[text size=80 default="Nutrition includes milk and a variety of foods. "]
[text size=80 default="Vitamins/Fluoride "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No significant sleep issues. "]
[text size=80 default="No significant reaction to previous immunizations. "]
[text size=80 default="No lead risk/Not exposed to housing 1950 or older. No TB risk/exposure to TB is unlikely. Neither parent with cholesterol greater than 300. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('4 year')"]
[text size=80 default="Has been generally healthy over the past year. "]
[text size=80 default="Nutrition includes milk and a variety of foods. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('5 year')"]
[text size=80 default="Has been generally healthy over the past year. "]
[text size=80 default="Nutrition includes milk and a variety of foods. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="No concerns regarding school readiness. "]
[text size=80 default="No previous reaction to immunizations. "]
[text size=80 default="No lead exposure risk. "]
[text size=80 default="No tobacco exposure. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('6-10 year')"]
[text size=80 default="Has been generally healthy over the past year. "]
[text size=80 default="Nutrition includes a variety of foods and good milk intake. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="Exercise is regular. "]
[text size=80 default="No height/weight concerns. "]
[text size=80 default="No school performance or social interaction concerns. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Denies smoking. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')"]
[text size=80 default="Has been generally healthy over the past year. "]
[text size=80 default="Nutrition includes a variety of foods and good milk intake. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="Exercise is regular. "]
[text size=80 default="No height/weight concerns. "]
[text size=80 default="No school performance or social interaction concerns. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Denies sexual activity, smoking, alcohol or other drug use. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('15-18 year')"]
[text size=80 default="Has been generally healthy over the past year. "]
[text size=80 default="Nutrition includes a variety of foods and good milk intake. "]
[text size=80 default="Growth is normal. "]
[text size=80 default="Exercise is regular. "]
[text size=80 default="No height/weight concerns. "]
[text size=80 default="Education and work plans ***. "]
[text size=80 default="Denies depression/anhedonia. "]
[text size=80 default="No problems with urine or stool. "]
[text size=80 default="Denies sexual activity, smoking, alcohol or other drug use. "]
[text size=80 default="All other systems are negative."][/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month')||(Q1).is('12 month')"]

NUTRITION
[select value="normal|not applicable|NOT ON TRACK"] <-- Breast Feeding
0-2 months: on demand, 10-12 feedings daily
2-4 months: on demand, 10-12 feedings daily
4-6 months: 8-10 feedings daily
6-8 months: 6-8 feedings daily
8-10 months: 4-6 feedings daily
over 10 months: may wean
[select value="normal|not applicable|NOT ON TRACK"] <-- Iron-Fortified Formula
0-2 months: 6-8 feedings, 16-26 ounces daily.
2-4 months: 4-6 feedings, 26-32 ounces daily
4-6 months: 26-40 ounces daily
6-8 months: 24-32 ounces daily
8-10 months: 20-24 ounces daily
10-12 months: 16-24 ounces daily. offer dairy products such as plain yogurt or mild cheese.
over 12 months: 2-3 cups 2% or whole milk. NO MORE BOTTLES
[select value="normal|NOT ON TRACK"] <-- Cereal
0-4 months: none
4-6 months: 1-2 tablespoons twice daily, thin with breast milk or formula, start with rice cereal.
6-8 months: ¼ to ½ cup baby cereal mixed with breast milk or formula
8-10 months: ¼ to ½ cup cereals, toast, mashed potato, rice or noodles
10-12 months: thicker cereal, increase serving size according to appetite
over 12 months: 4 servings per day
[select value="normal|NOT ON TRACK"] <-- Vegetables
0-6 months: none
6-8 months: strained vegetables 3-4 Tbsp. twice daily. start with green, then yellow type.
8-10 months: may advance to junior strained vegetables or tender vegetables from the table.
10-12 months: increase serving size according to appetite.
over 12 months: 2-3 small servings daily. Offer a variety.
[select value="normal|NOT ON TRACK"] <-- Juices/Fruits
0-6 months: none
6-8 months: unsweetened juice from cup, vitamin C fortified, no more than1/2 cup daily. begin with apple juice. start with baby juice or dilute adult juice (half juice, half water).
8-10 months: limit to 1/2 cup unsweetened juice daily. begin strained fruits 3-4 tbsp. twice daily.
10-12 months: continue to limit to 1/2 cup unsweetened juice daily. 3-4 Tbsp. strained fruit per day. Soft pieces of ripe, raw, peeled fruit.
over 12 months: 2-3 small servings of fruit or juice daily. Offer a variety. Limit juice to 4 oz. daily.
[select value="normal|NOT ON TRACK"] <-- Meats/Eggs/Protein
0-8 months: none
8-10 months: strained meat, baby egg yolk or hard cooked egg yolk, 1-2 Tbsp. daily. well-cooked beans or peas.
10-12 months: 1-2 Tbsp. finely chopped meats once or twice daily.
over 12 months: 2 one ounce servings of protein foods such as meat, eggs, dried beans, peas.
[select value="normal|NOT ON TRACK"] <-- Soda Pop
NEVER![/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month')||(Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('2 year')||(Q1).is('3 year')||(Q1).is('4 year')"]

DEVELOPMENT
[select value="normal|NOT ON TRACK"] <-- Cognitive Milestones
3 to 5 months: Attends to and reaches for objects
4 to 8 months: Pulls string to secure a ring
8 to 15 months: Imitates patting doll
12 months: Follows 1-step command
14 to 20 months: Finds hidden object
18 months: Points to 1 body part
18-28 months: Completes simple puzzles
24 months: Follows 2-step command
30 months: Points to 6 body parts
[select value="normal|NOT ON TRACK"] <-- Language Milestones
1 ½ to 3 months: Squeals
3 ½ to 8 months: Turns to locate a rattle, voice
6 months: Laughs, coos
9 to 13 months: Says Mama or Dada (non-specific), babbles, single syllables
12 months: Imitates vocalizations and sounds, Says one word
15 months: Says 1-3 words
18 months: Says 3-6 words
21 to 36 months: Uses Plurals
24 months: Combines two different words, names one picture
30 months: Speech half understandable
36 to 48 months: Speech all understandable, names four pictures and 1-4 colors
[select value="normal|NOT ON TRACK"] <-- Social/Emotional Milestones
1 ½ to 4 months: Smiles at others
4 to 9 months: Seeks primary caregiver
8 to 15 months: Stranger anxiety
9 to 12 months: Waves bye-bye
10 to 15 months: Displays 2 or more recognizable emotions
11 to 20 months: Exploratory play by self
21 to 36 months: Cooperative play in small groups
[select value="normal|NOT ON TRACK"] <-- Gross Motor Milestones
2 to 4 ½ months: Rolls over
5 to 8 months: Sits without support
10 to 14 months: Stands alone
14 to 20 months: Walks up steps
30 to 44 months: Balances on one foot
[select value="normal|NOT ON TRACK"] <-- Fine Motor Milestones
2 ½ months to 4 months: Grasps rattle
4 ½ to 7 months: Transfers cube hand to hand
8 to 12 months: Has neat pincer grasp
15 to 20 months: Builds tower of four cubes
18 to 24 months: Imitates vertical line
28 to 36 months: Copies circle
[select value="normal|NOT ON TRACK"] <-- Self Help Milestones
4 ½ to 8 months: Feeds self crackers
10 to 14 months: Drinks from cup
13 to 19 months: Removes clothes
18 to 28 months: Washes and dries hands
30 to 42 months: Dresses without supervision[/conditional]

OBJECTIVE/EXAMINATION:
[conditional field="Q1|Q2" condition="(Q1).is('1 week')&&(Q2).is('male')"]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light"]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Peripheral Vessels: Normal pulses and perfusion."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia. Testes descended bilaterally. No hernia present."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Hips with full range-of-motion; negative Barlow and Ortolani."]
[text size=80 default="Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="(Q1).is('1 week')&&(Q2).is('female')"]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light"]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Peripheral Vessels: Normal pulses and perfusion."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia. No hernia present."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Hips with full range-of-motion; negative Barlow and Ortolani."]
[text size=80 default="Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. "]
[text size=80 default="Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('2 year')||(Q1).is('3 year')||(Q1).is('4 year'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('2 year')||(Q1).is('3 year')||(Q1).is('4 year'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('5 year')||(Q1).is('6-10 year')||(Q1).is('11-14 year')||(Q1).is('15-18 year'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert, oriented, in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional][conditional field="Q1|Q2" condition="((Q1).is('5 year')||(Q1).is('6-10 year')||(Q1).is('11-14 year')||(Q1).is('15-18 year'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="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."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert, oriented, in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."][/conditional]

ASSESSMENT/PLAN:
[conditional field="Q1" condition="(Q1).is('1 week')"]
[textarea cols=144 default="#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 less than 120 degrees and test fire alarms. "]
[textarea cols=144 default="No immunizations/Hepatitis B given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('2 month')"]
[textarea cols=144 default="#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."]
[textarea cols=144 default="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."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('4 month')"]
[textarea cols=144 default="#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."]
[textarea cols=144 default="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."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('6 month')"]
[textarea cols=144 default="#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. "]
[textarea cols=144 default="Side effects, risks and benefits of immunizations. Immunizations today: DTaP (Diphtheria-Tetanus-acellular Pertussis)/HBV (hepatitis)/PCV7 (Pneumococcal)/ROTA (Rotavirus)"]
[textarea cols=144 default="Return appointment: age nine months/age twelve months/age fifteen months or sooner if needed."][/conditional][conditional field="Q1" condition="(Q1).is('9 month')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="Return to clinic at 12 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."][/conditional][conditional field="Q1" condition="(Q1).is('12 month')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('15 month')"]
[textarea cols=144 default="#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."]
[textarea cols=144 default="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"]
[textarea cols=144 default="Side effects, risks and benefits of immunizations discussed. Immunizations today: DTaP/Hib/PCV7/Influenza vaccine/HAV"]
[textarea cols=144 default="Return appointment: age two years/age 18 month visit with doctor/age 18 month visit with nurse for immunizations or sooner if needed."][/conditional][conditional field="Q1" condition="(Q1).is('2 year')"]
[textarea cols=144 default="#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."]
[textarea cols=144 default="No immunizations given today/Influenza/Hepatitis A/Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('3 year')"]
[textarea cols=144 default="#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."]
[textarea cols=144 default="No immunizations given today/Immunizations given today/MMR (Measles-Mumps-Rubella)/Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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). "]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('4 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="No immunizations given today/Immunizations given today.. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('5 year')"]
[textarea cols=144 default="#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"]
[textarea cols=144 default="Immunizations today: None/DTaP/MMRV/IPV/Flu/Hep A. Side effects, risks and benefits of immunizations."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('6-10 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="Immunizations given/No immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('15-18 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="Immunizations given. Side effects, risks, and benefits of immunizations discussed/No immunizations given today."]
[textarea cols=144 default="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."][/conditional]
<-- Age
<-- Gender
SUBJECTIVE/HISTORY:


OBJECTIVE/EXAMINATION:


ASSESSMENT/PLAN:
Result - Copy and paste this output:

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