Well child – 4 mo

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"]
SPECIAL NEEDS: [textarea cols=80 rows=1][checkbox name="special" value="none|specialty"]
SOCIAL HISTORY: [textarea cols=80 rows=1][checkbox name="risk" value="no changes|child care|housing|single parent|working parent|siblings|maternal depression"]

REVIEW OF SYSTEMS
Interval change: [textarea cols=80 rows=1][checkbox name="concerns" value="doing well, no changes since last visit|no illnesses or injuries|no specific concerns raised|no visits to health care providers, facilities|questionnaire provided & reviewed"]

Nutrition: [textarea cols=80 rows=1][checkbox name="nutrition" value="no concerns|breast|formula"]
Urination: [textarea cols=80 rows=1][checkbox name="elimination" value="no concerns"]
Stooling: [textarea cols=80 rows=1][checkbox name="stooling" value="no concerns"]
Sleep: [textarea cols=80 rows=1][checkbox name="sleep" value="no concerns"]

GROWTH: [textarea cols=80 rows=1][checkbox name="weight" value="chart provided, reviewed, developing well"]
MILESTONES: [textarea cols=80 rows=1][checkbox name="milestones" value="pushes chest up to elbows, adequate head control, rolls over from stomach to back|reaches for objects, opens hands, grasps rattle|smiles, babbles & coos, responds to affection, social smile, recognizes parent’s voice & touch"]

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Appearance: [textarea cols=80 rows=1][checkbox name="appearance" value="well-appearing|active, interactive|no distress|uncooperative with exam"]
Skin: [textarea cols=80 rows=1][checkbox name="skin" value="pink, normal turgor|no rashes|no bruises"]
Head: [textarea cols=80 rows=1][checkbox name="head" value="no skull deformities|normal anterior fontanelle|plagiocephaly"]
Eyes: [textarea cols=80 rows=1][checkbox name="eyes" value="blinks to light, red reflex bil, appears to see|no strabismus"]
Ears: [textarea cols=80 rows=1][checkbox name="ears" value="appears to hear|normal canals & TMs"]
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|teeth absent|bottom central incisor(s) 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, clear and equal breath sounds bilaterally"]
Heart: [textarea cols=80 rows=1][checkbox name="heart" value="regular rate & rhythm, no murmurs|femoral pulses present & equal"]
Abdomen: [textarea cols=80 rows=1][checkbox name="abdomen" value="soft, nondistended, nontender, no obvious palpable masses, bowel sounds normal"]
Genitalia: [textarea cols=80 rows=1][checkbox name="genitalia" value="normal appearance|uncircumcised| circumcised|testes down bilaterally"]
Extremities: [textarea cols=80 rows=1][checkbox name="extremities" value="symmetrical FROM, hips w/ good abduction w/o clicks"]
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, normal & symmetrical tone/strength"]

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

IMMUNIZATION: [textarea cols=80 rows=1][checkbox name="immunization" value="per schedule|deferred|declined"]

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="guidance" value="exam findings & recommendations|diagnostic studies|development, growth, safety, falls, drowning, no walkers|nutrition, trying solids & different foods to avoid allergy, no bottle in bed, oral health|daily routines, tummy time, sleep|given opportunity to ask questions and state concerns|verbalized understanding of instructions & POC"]

FOLLOW UP: [textarea cols=80 rows=1][checkbox name="follow" value="6 months of age, sooner if concerns arise"]