‘3yoWCC

Patient is a 3 yo _ who presents for WCC.

– Diet: No concerns.
– Voiding/stooling: No concerns. + toilet trained (during the day, at least).
– Sleeping: No concerns. Has regular bedtime routine.
– Dental: Weaned from the bottle. + brushes teeth. Has been to the dentist.
– Behavior: No concerns.
– Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.

PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:
– Gross and fine motor: Can stack 6-8 blocks, stand on one foot, pedal a tricycle, throw a ball overhand, walk up stairs with alternating feet, copy a circle, draw a person with two body parts, dress self (may need some help).
– Cognitive: Knows name, age, sex. Counts to 3 or more.
– Social/Emotional: Joins other children in play. Asks questions. Able to name friends.
– Communication: Others can understand at least 3/4 of what is said. Speaks in 3-4 word sentences. MCHAT in chart.

SOCIAL:
– No smokers in the home.
– No major social stressors at home.
– No safety concerns in the home.
– Daytime child care is with _
– No TB or lead risk factors.

IMMUNIZATIONS:
– Up to date.