Pediatrics
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HISTORY: [textarea cols=80 rows=1][checkbox name="informant" value="provided by parent|provided by other|unobtainable d/t parental anxiety and/or lack of knowledge|interpretation provided by family member|interpretation provided by MA"]

Hospital: [textarea cols=80 rows=1]
Born: [textarea cols=10 rows=1][checkbox name="born" value="term|postterm|preterm"]
BW: [textarea cols=10 rows=1]
Bilirubin: [textarea cols=10 rows=1][checkbox name="bili" value="unknown|NL"]
Hep B: [textarea cols=10 rows=1][checkbox name="hepb" value="maternal Neg|maternal Pos|maternal Unk|vaccine given|vaccine not given"]
Newborn screening: [textarea cols=80 rows=1][checkbox name="screening" value="pending|unknown|normal"]
Hearing screening: [textarea cols=80 rows=1][checkbox name="hearing" value="passed per parent|unknown|pending"]

SPECIAL NEEDS: [textarea cols=80 rows=1][checkbox name="special" value="none|specialty"]
FAMILY HISTORY: [textarea cols=80 rows=1][checkbox name="FHx" value="reviewed|Neg"]
SOCIAL HISTORY: [textarea cols=80 rows=1][checkbox name="risk" value="none|child care|housing|single parent|working parent|siblings|maternal depression"]
CONCERNS: [textarea cols=80 rows=1][checkbox name="concerns" value="none raised|questionnaire provided|reviewed"]

REVIEW OF SYSTEMS
General: [textarea cols=80 rows=1][checkbox name="child" value="doing well, alert to sights and sounds, quiets with comforting"]
Nutrition: [textarea cols=10 rows=1][checkbox name="nutrition" value="no concerns|breast|formula|on demand|10-12 per day"]
Urination: [textarea cols=10 rows=1][checkbox name="urination" value="no concerns|6-8 wet diapers per day"]
Stooling: [textarea cols=10 rows=1][checkbox name="stooling" value="no concerns|passed meconium|green|yellow|soft"]
Sleep: [textarea cols=80 rows=1][checkbox name="sleep" value="no concerns|crib"]

DEVELOPMENT: [textarea cols=80 rows=1][checkbox name="weight" value="growth chart provided, discussed, developing well"]
MILESTONES: [textarea cols=80 rows=1][checkbox name="milestones" value="sucks, swallows, breathes easily|follows face|turns and calms to caregiver voice"]

EXAM
Appearance: [textarea cols=80 rows=1][checkbox name="appearance" value="well-appearing|active, interactive|strong suck|crying|easily consoled|NWOB|moist mucous membranes|uncooperative with exam"]
Skin: [textarea cols=80 rows=1][checkbox name="skin" value="pink, normal turgor|no jaundice|no bruises|erythema toxicum|milia"]
Head: [textarea cols=80 rows=1][checkbox name="head" value="no skull deformities|both fontanelles open & soft||swelling"]
Eyes: [textarea cols=80 rows=1][checkbox name="eyes" value="anicteric sclerae, blinks to light, red reflex bil|no discharge in corners|palpebral exudate"]
Ears: [textarea cols=80 rows=1][checkbox name="ears" value="normal position, turns to sound"]
Nose: [textarea cols=80 rows=1][checkbox name="nose" value="nares patent"]
Mouth: [textarea cols=80 rows=1][checkbox name="mouth" value="oral mucosa moist & without lesions, tongue normal in appearance/size & with good movements, normal palate|strong suck|teeth not present"]
Throat: [textarea cols=80 rows=1][checkbox name="throat" value="patent pharynx w/o swelling or exudates"]
Neck: [textarea cols=80 rows=1][checkbox name="neck" value="supple, symmetrical ROM, turns head side to side"]
Chest: [textarea cols=80 rows=1][checkbox name="chest" value="unlabored respirations, symmetric chest expansion, clavicles nontender & symmetrical, clear and equal breath sounds bilaterally"]
Heart: [textarea cols=80 rows=1][checkbox name="heart" value="regular rate & rhythm, no murmurs"]
Abdomen: [textarea cols=80 rows=1][checkbox name="abdomen" value="soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal|umbilicus healing w/o infection"]
Genitalia: [textarea cols=80 rows=1][checkbox name="genitalia" value="normal appearance|uncircumcised| circumcised healing well|testes down bilaterally"]
Extremities: [textarea cols=80 rows=1][checkbox name="extremities" value="symmetrical FROM, normal palmar creases, five digits, hips w/ good abduction w/o clicks"]
Peripheral vascular: [textarea cols=80 rows=1][checkbox name="peripheral" value="femoral pulses present & equal, normal perfusion"]
Back: [textarea cols=80 rows=1][checkbox name="back" value="normal spine|no sacral dimpling"]
Neuro: [textarea cols=80 rows=1][checkbox name="neuro" value="normal reflexes, newborn reflexes present & symmetrical, normal & symmetrical tone/strength"]

LABORATORY/OFFICE DIAGNOSTICS: [textarea cols=60 rows=1][checkbox name="diagnostics" value="none|non-specific changes|reviewed & discussed with parent|normal|non-specific changes|official report to follow|pending"]

IMMUNIZATION: [textarea cols=80 rows=1][checkbox name="immunization" value="none|per schedule|next visit"]

OUTSIDE ORDERS/REFERRALS: [textarea cols=80 rows=1][checkbox name="orders" value="none|laboratory studies|diagnostic studies|specialty|WIC"]

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED: [textarea cols=80 rows=1][checkbox name="guide" value="crib safety, back to sleep, no bottle in bed, hand on baby, smoke detectors, hot liquids, smoke-free environment|signs of illness|feeding, burping, no solids, no honey, no cow milk|elimination|cord care|circumcision care|calming techniques"]


FOLLOW UP: [textarea cols=80 rows=1][checkbox name="follow" value="2 months of age, sooner if concerns arise"]
HISTORY:

Hospital:
Born:
BW:
Bilirubin:
Hep B:
Newborn screening:
Hearing screening:

SPECIAL NEEDS:
FAMILY HISTORY:
SOCIAL HISTORY:
CONCERNS:

REVIEW OF SYSTEMS
General:
Nutrition:
Urination:
Stooling:
Sleep:

DEVELOPMENT:
MILESTONES:

EXAM
Appearance:
Skin:
Head:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Chest:
Heart:
Abdomen:
Genitalia:
Extremities:
Peripheral vascular:
Back:
Neuro:

LABORATORY/OFFICE DIAGNOSTICS:

IMMUNIZATION:

OUTSIDE ORDERS/REFERRALS:

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED:


FOLLOW UP:
Result - Copy and paste this output: