Newborn Visit - Tennessee's Voice for Children & · PDF file · 2017-04-27Physical...

Physical Exam Undressed: o yes o noB/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_

Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWet Diapers Per Day _________________Strong stream (if Male)? o Yes o NoStools per day ______________________WIC o Yes o No

Problems Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoExcessive crying o Yes o No______________________________________________________________________________________________________Family History _____________________Social History ______________________Hearing Risk AssessmentResponds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________

Vision Risk AssessmentLooks at parent’s face o Yes o No

Newborn Metabolic/HemoglobinopathyScreening o Normal o Repeat o Pending

Critical Congenital Heart Disease o Normal o Repeat o Pending

Developmental Surveillanceo Yes o No Concerns? _____________

Psychosocial/Behavioral Surveillanceo Yes o No Concerns? _____________

Delivery Historyo Discharge Date _____o Hospitalo Gestational Age _____o SVD or C/So Membranes ruptured ___ hourso GBS: + -o Maternal labs ____o Baby blood type ___ Maternal blood type ___o HGB given: yes no o Birth weight __________________ o Discharge weight __________________o Complications __________________

Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety, no blankets, 2-inch slatso Firm well fitting crib mattresso Never shake the baby

Healtho If bottle fed feedings 26 – 32 oz per dayo Sponge batheo Cord, circumcision careo Bowel movementso Fever > 100.4 o Discuss breastfeeding o No solids until 6 months o Discuss Well visit schedule o No Honey

Social/Behavioralo Parent/Child interactiono Sleepo Cuddle, talk, rocko Support for mothero Who makes up family

Impressiono Well Newborno Premature Infanto Jaundiceo ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Hep B #1 (if indicated)o V.I.S./Counseling o Influenza/TdaP for caregiverso Vitamin D if breastfed 400 IU/Do Lactation consulto RTC at 1 month __________________o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________

_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlUmbilical Cord --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl Circ. ---------- o nl o abnl

American Academy of PediatricsDEDICATED TO THE HEALTH OF ALL CHILDRENTM

Tennessee Chapter

®

Newborn Visit

Date _______________________ Form revised 06/16

Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Length ______ in. W/L _____ %tile Head circ. _____cm Temp. _____AX REC

Physical Exam Undressed: o yes o noB/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_

Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWet Diapers Per Day _________________Strong stream (if Male)? o Yes o NoStools per day ______________________WIC o Yes o No

Problems Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoExcessive crying o Yes o No______________________________________________________________________________________________________Family History _____________________Social History ______________________Hearing Risk AssessmentResponds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________

Vision Risk AssessmentLooks at parent’s face o Yes o No


Critical Congenital Heart Disease o Normal o Repeat o Pending



Delivery Historyo Discharge Date _____o Hospitalo Gestational Age _____o SVD or C/So Membranes ruptured ___ hourso GBS: + -o Maternal labs ____o Baby blood type ___ Maternal blood type ___o HGB given: yes no o Birth weight __________________ o Discharge weight __________________o Complications __________________

Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety, no blankets, 2-inch slatso Firm well fitting crib mattresso Never shake the baby

Healtho If bottle fed feedings 26 – 32 oz per dayo Sponge batheo Cord, circumcision careo Bowel movementso Fever > 100.4 o Discuss breastfeeding o No solids until 6 months o Discuss Well visit schedule o No Honey

Social/Behavioralo Parent/Child interactiono Sleepo Cuddle, talk, rocko Support for mothero Who makes up family

Impressiono Well Newborno Premature Infanto Jaundiceo ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Hep B #1 (if indicated)o V.I.S./Counseling o Influenza/TdaP for caregiverso Vitamin D if breastfed 400 IU/Do Lactation consulto RTC at 1 month __________________o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________




Tennessee Chapter

®



3 to 5 Day Visit

B/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_

Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottledWIC o Yes o No

Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________

Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoStuffy nose o Yes o NoColic o Yes o No______________________________________________________________________________________________________Hearing Risk Assessment

Responds to sounds o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled ________

Vision Risk AssessmentLooks at parent’s face o Yes o NoFollows with eyes o Yes o No


TB Risk Assessment* — +



Maternal Postpartum Depression Screen — +

Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safety: 2-inch slats, no objects in bedo Never shake the baby

Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Delay solidso Bowel movementso Strong urinary stream if maleo Fever o No Honey

Social/Behavioralo Tempermento Sleepo Talk to babyo Support for mother

Impressiono Well Newborno Normal Growtho Normal Developmento ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Influenza/TdaP for caregivers o Hep Bo V.I.S./Counselingo Vitamin D if breast fed 400 IU/Do One month Handout sheet o PPD if at risko RTC at 2 monthso Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________



Physical Exam Undressed: o yes o no

* see separate form


Tennessee Chapter

®

One Month Visit



B/P if indicated _________ / ________ RA _/_ LA _/_ RL _/_ LL _/_


Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _________________________________________________________

Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoStuffy nose o Yes o NoColic o Yes o NoDiaper rash o Yes o No

Hearing Risk AssessmentResponds to sounds o Yes o NoSmiles and laughs o Yes o NoNewborn hearing screen:o Passed o Repeat scheduled o Not done


Newborn Metabolic/Hemoglobinopathy Screening:o Normal o Repeat o Pending




Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Safe sleep/sleep on backo Crib safetyo Rolling over, prevent falls

Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Delay solidso Bowel movementso Strong urinary stream if maleo Fever o No Honey

Social/Behavioralo Tempermento Sleepo Talk to babyo Support for mother

Impressiono Well Newborno Normal Growtho Normal Developmento ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Influenza/TdaP for caregivers o Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo V.I.S./Counselingo Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Two month Handout sheeto RTC at 4 months o Parent declination of treatment ______o Referrals _______________________o ________________________________o ________________________________


General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips ---------------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl



Tennessee Chapter

®

Two Month Visit



B/P if high risk: _________ / ________


Anemia Risk Assessment — + Preterm ___ Low birth weight ___ Breast feeding ____ Low iron formula ____


Constipation o Yes o NoSleep o Yes o NoSpitting up o Yes o NoDiaper rash o Yes o No

Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoBabbles and coos o Yes o No






Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso No bottle proppingo Roll over, fall preventiono Bath safety o Safe sleep/sleep on backo No baby walkerso Child proof home

Healtho If bottle fed, 26 – 32 oz per dayo If breast fed, nurses 8-10 times/dayo Introduce solidso Avoid honeyo Teething

Social/Behavioralo Tempermento Sleep, bedtime routineo Talk, read to babyo Family support

Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo V.I.S./Counselingo Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Four month Handout sheeto RTC at 6 months o Iron supplement: 2 mg/kg/d if preterm or low birth weighto1 mg/kg/d if low iron formula or breastfed o Hgb if at risko Parent declination of treatment ______o Referrals _______________________o ________________________________





Tennessee Chapter

®

Four Month Visit



B/P if high risk: _________ / ________

Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoCereal/baby food o Yes o NoWater: o city o well o spring o bottled o fluoridatedWIC o Yes o No


Constipation o Yes o NoSleep o Yes o NoDiaper rash o Yes o No

Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoJabbers and laughs o Yes o No


Dental Risk Assessment* — + TB Risk Assessment* — + Lead Risk Assessment* — +



Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso Always supervise batho Rolling over, fall prevention o Safe sleep/sleep on backo No baby walkerso Child proof home o Sunburn prevention

Healtho Continue formula or breast milko Introduce cereal, vegetables, fruits, meatso Introduce cupo Avoid honeyo Teething/clean teeth o Physical activity o No bottle in bed or bottle propping

Social/Behavioralo Tempermento Sleep, bedtime routineo Talk, read to babyo Family supporto No TV/media

Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, Rotavirus, DTaP, Hib, PCV-13, IPVo Influenza vaccine o V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Six month Handout sheet o Hgb if at risko Lead level if at risko RTC at 9 months o Poison Control o Refer to dental home if risk assessment + o Fluoride Varnish o Iron supplement: 2 mg/kg/d if preterm or low birth weight; 1 mg/kg/d if low iron formula or breastfedo Parent declination of treatment ______ o Referrals _______________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation



* see separate form


Tennessee Chapter

®

Six Month Visit



B/P if high risk: _________ / ________

Nutritiono Breast _________min. q. ________ hrs.o Formula ________oz. q. _________ hrs.Brand _____________________________With iron? o Yes o NoWater: o city o well o spring o bottled o fluoridatedBaby food__________servings per day Table food o Yes o No WIC o Yes o No


Speech/Hearing Risk AssessmentResponds to sounds o Yes o NoImitates speech o Yes o No

Vision Risk AssessmentNotices small objects o Yes o No

Dental Risk Assessment* — + Lead Risk Assessment* — +



Developmental Screeningo Normal o Abnormal

Safetyo Car seat, facing backwardso Smoke free environmento Smoke detectors in homeo Hot water < 120 degreeso Always supervise batho Fall prevention/gateso Poison Control numbero Child proof home o Safe sleep/sleep on back o Sunburn preventionHealtho Continue formula or breast milko Introduce table, finger foodo Choking preventiono Introduce cup, weaningo Avoid honey o Physical activityo Teething/clean teeth o No bottle in bed or bottle proppingSocial/Behavioralo Exploring, set consistent limitso Sleep, bedtime routineo Talk, read to babyo Separation Anxiety o Family support o No TV/mediao Day care o Yes o No

Impressiono Well Babyo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, DTaP, Hib, PCV-13, IPVo Influenza vaccine o V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin D if breast fed 400 IU/Do Dental referral (if at risk) o Fluoride Varnish o Lead level if at risk o Nine month Handout sheeto RTC at 12 months o Iron supplement: 2 mg/kg/d if preterm or low birth weight; 1 mg/kg/d if low iron formula or breastfedo Parent declination of treatment ______ o Referrals _______________________o ________________________________




* see separate form


Tennessee Chapter

®

Nine Month Visit



B/P if high risk: _________ / ________

NutritionWhole milk o Yes o NoWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No


Speech/Hearing Risk AssessmentHears well o Yes o NoSays 2-4 words o Yes o No


Photorefractive Screen — + Dental Risk Assessment* — + TB Risk Assessment* — +

Lead Risk Assessment* — +



Safetyo Car Seat, facing backward o Smoke detectors in homeo Hot water < 120 degreeso Water safety, supervise batho Close supervisiono Child proof home o Safe sleep/sleep on backo Poison Control Number o Sunburn prevention

Healtho Weaningo Introduce whole milk from cupo Limit juice, milk intakeo Changes in appetiteo Introduce table, finger foods o Choking prevention o Physical activity o Teething/clean teeth

Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Sleep, bedtime routineo Talk, read to childo Family o No TV

Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, Hib, PCV-13, IPV, MMR, Varicella, Hep Ao Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Vitamin drops with irono Dental referral o Fluoride Varnish o PPD if at risko 12 month Handout sheeto RTC at 15 months o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________Lab Test Lead level__________________________________ (Required by TennCare)Hgb _____________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl


* see separate form


Tennessee Chapter

®

12 Month Visit



B/P if high risk __________ / ________





Anemia Risk Assessment* — +Preterm ___ Low birth weight ___ Breast feeding ____ Low iron formula ____




Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfgo Smoke detectors in homeo No smoking in homeo Hot water < 120 degreeso Water safety, supervise bath

Safety (continued)o Close supervisiono Child proof homeo Poison Control Number o Sunburn prevention

Healtho Weaningo Whole milk until age 2o Limit juice, milk intakeo Picky appetites, self feedingo Offer varitety of foods o Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o d/c pacifier/bottle o Physical activity o Brushing teeth

Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Discourage hitting, biting and other aggressive behavioro Sleep, bedtime routineo Talk, read to childo Family o No TV

Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Hep B, DTaP, Hib, PCV-13, IPV, MMR, Varicella, Hep Ao Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrs.o Fluoride Varnisho Vitamin drops with irono 15 month Handout sheeto RTC at 18 months o Parent declination of treatment ______ o Referrals _______________________o ________________________________Lab Test Hgb ______________________________ (If not done at 12 months) Lead level _________________________ (If TennCare and not done at 12 months)_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------ o nl o abnlHead ---------------- o nl o abnlFontanel ----------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl


* see separate form


Tennessee Chapter

®

15 Month Visit



B/P if high risk __________ / ________





Dental Risk Assessment* — + Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____


Developmental Surveillance o Yes o No Concerns? _____________


Developmental Screening* o Normal o Abnormal Autism Screening* o Normal o Abnormal

Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfgo Smoke detectors in homeo No smoking in homeo Hot water < 120 degrees

Safety (continued)o Water safety, supervise batho Close supervisiono Child proof homeo Poison Control Number o Sunburn prevention

Healtho Weaningo Whole milk until age 2o Limit juice, milk intakeo Picky appetites, self feedingo Offer varitety of foods o Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teeth

Social/Behavioralo Set consistent limits, disciplineo Praise good behavioro Time out, tantrumso Talk, read to childo Family o Imitative/parallel playo No TV

Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________

Plan/Referralso Immunizations current? o Yes o Noo Hep B, MMR, Varicella, Hep A, DTaP, Hib, PCV-13, IPVo Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrso Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risko 18 month Handout sheeto RTC at 2 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________


General ------------ o nl o abnlHead ---------------- o nl o abnlNeck ---------------- o nl o abnlEyes ---------------- o nl o abnl Red reflex ------ o nl o abnl Alignment ----- o nl o abnlEars ---------------- o nl o abnlNose ---------------- o nl o abnlThroat/Mouth ---- o nl o abnlLungs--------------- o nl o abnlHeart --------------- o nl o abnlAbdomen ---------- o nl o abnlFemoral Pulses --- o nl o abnlSpine --------------- o nl o abnlExtremities -------- o nl o abnlHips/Gait --------- o nl o abnlSkin ---------------- o nl o abnlNeuro --------------- o nl o abnlGenitalia Female ---------- o nl o abnl Male ------------ o nl o abnl Testes --------- o nl o abnl


* see separate form


Tennessee Chapter

®

18 Month Visit



B/P: _________ / ________ (meaningful use or if indicated)

NutritionWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________

Dyslipidemia Risk Assessment — +FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____

Speech/Hearing Risk AssessmentHears well o Yes o No2-3 word sentences o Yes o No

Vision Risk AssessmentSees distant objects well? o Yes o No

Photorefractive Screen — + Dental Risk Assessment* — +Anemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ TB Risk Assessment* — + Lead Risk Assessment* — +Developmental Surveillance o Yes o No Concerns? _____________


Developmental Screening* o Normal o Abnormal Autism Screening* o Normal o Abnormal

Safetyo Car Seat, facing backward until age 2 or > weight and height allowed by mfg o Use bike helmeto Smoke detectors in homeo No smoking in homeo Hot water < 120 degreeso Water safety, supervise batho Child proof home, supervisiono Poison Control Number o Firearm safety o Sunburn prevention

Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teethSocial/Behavioral

o Set limits, time outo Praise good behavioro TV/Media < 2 hrs/dayo Read to child o Toilet trainingo Sleep, bedtime routineo Family


Plan/Referralso Immunizations current? o Yes o Noo Hep B, Hep A, DTaP, IPVo Influenza vaccineo V.I.S./Counselingo Ibuprofen ___ mg. q. 6-8 hours o Acetaminophen__________mg. q. 4-6 hrso Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risko 2 year Handout sheeto RTC at 2 1/2 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________Lab Test Lead Level _________________________(Required by Tenncare at 12 and 24 months.)

_______________ M.D. / P.N.P. / DO / PAPROV# ___________________________

o See back for additional documentation



* see separate form


Tennessee Chapter

®

24 Month Visit


Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height ______ in. BMI _____ %tile Head circ. _____cm Temp. _____AX Oral

B/P: _________ / ________ (meaningful use or if indicated)

NutritionWeaned from bottle o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No

Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — +FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____

Speech/Hearing Risk AssessmentHears well o Yes o No2-3 word sentences o Yes o No

Vision Risk AssessmentSees distant objects well? o Yes o No

Dental Risk Assessment* — + Anemia Risk Assessment* — + Poverty ___ Poor Diet ____ Chronic Illness _____



Developmental Screening* o Normal o AbnormalSafetyo car seat in back forward facing o Use bike helmeto Smoke detectors in homeo No smoking in homeo Hot water < 120 degrees

Safety (continued)

o Water safety, supervise batho Child proof home, supervisiono Poison Control Number o Firearm safety o Sunburn prevention

Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Choking prevention o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day o Physical activity o Brushing teeth

Social/Behavioralo Set limits, time outo Praise good behavioro TV/Media - < 2 hrs/dayo Read to child o Toilet trainingo Sleep, bedtime routineo Familyo Day care, pre-school o Yes o No


Plan/Referralso Immunizations current? o Yes o Noo Hep Ao Influenza vaccineo V.I.S./Counselingo Vitamin drops with iron o Dental referral o Fluoride Varnish o Hgb if at risko 2 1/2 year Handout sheeto RTC at 3 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________




* see separate form


Tennessee Chapter

®

30 Month Visit


Name _____________________________________________ Birth Date _________________ Age ___________ Historian ________________ Allergies __________________ Medications _______________________________Weight______lbs. _____ oz. Height _________in. BMI ________ %tile Temp. _______AX Oral

B/P: ________ / ________

NutritionLow fat milk, cup only o Yes o NoAppetite o good o variable o picky fruits __________________________ vegetables ______________________ meats __________________________ bread __________________________Water: o city o well o spring o bottled o fluoridatedWIC o Yes o No

Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________

Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________

Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____Speech/Hearing Risk AssessmentHears well o Yes o NoTalks well o Yes o NoEasy to understand? o Yes o NoVision Vision screening test:L near 20/ ____________ far 20/ ___________ R near 20/ ____________ far 20/ ___________Photorefractive Screen — + Anemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + Dental Risk Assessment — + TB Risk Assessment* — +Developmental Surveillance o Yes o No Concerns? _____________


Safetyo Car seat in back forward facing o Bike helmeto Smoke detectors in homeo No smoking in homeo Water safety, supervise bath o Outdoor safety, supervisiono Poison Control Number o Firearm safety o Sunburn prevention

Healtho Low fat milk from cupo Limit juice, milk intakeo Picky appetites, self feedingo Low fat foods, healthy snacks o Brush teeth, see dentist o Encourage Active Play o 20-30% of calories from dietary fat o 10% of calories from saturated fat o 300 mg of cholesterol per day

Social/Behavioralo Discipline, time outo Praise good behavioro TV limits o Read to childo Self help skills o Toilet trainingo Family

Safety (continued)o Friends and playmates o Curiosity about sexo Day care, pre-school o Yes o NoImpressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 3 year Handout sheeto RTC at 4 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation



* see separate form


Tennessee Chapter

®

3 Year Visit



B/P: ________ / ________

NutritionAppetite o good o variable o pickyWater: o city o well o spring o bottled o fluoridatedWIC o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o No BP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____

Speech/Hearing Risk Assessment Hearing screening test o Pass o Abnormal o Unable to testVision Vision screening test:L near 20/ ____________ far 20/ ___________ R near 20/ ____________ far 20/ ___________Photorefractive Screen — + Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + TB Risk Assessment* — +



Safetyo Booster seat – rear seat – 4-8 years or < 4’9” tall o Never put child in front seat if you have air bagso Bike helmet

Safety (continued)

o Smoke detectors in homeo No smoking in homeo Water safety, swimming lessons o Outdoor safety, supervision o Firearm safety o Sunburn prevention

Healtho Low fat milk o Limit Juiceo Encourage fruits and vegetableso Brush teeth, see dentist o Encourage active play o < 20-30% of calories from dietary fat o < 10% of calories from saturated fat o < 300 mg of cholesterol per day

Social/Behavioralo Discipline, time outo Praise good behavioro Read to child o TV/Media – limit <2 hrs/day, monitor contento Dresses self, helps at home o Familyo Friends and playmates o Curiosity about sexo Day care, pre-school o Yes o No


Plan/Referralso Immunizations current? o Yes o Noo DTaP, IPV (4th dose on/after 4th bday), MMR, Varicella, Hep A o Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 4 year Handout sheeto RTC at 5 years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o ________________________________




* see separate form


Tennessee Chapter

®

4 Year Visit



B/P: ________ / ________

NutritionAppetite o good o variable o pickyWater: o city o well o spring o bottled o fluoridatedWIC o Yes o No

Interval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________

Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________

Speech/Hearing Risk AssessmentHearing screening test o Pass o Abnormal o Unable to test

Vision Vision screening test:L near 20/ __________ far 20/ ____________ R near 20/ __________ far 20/ ____________ photorefractive screen — +

Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Lead Risk Assessment* — + TB Risk Assessment* — +



Safetyo Booster seat – rear seat – 4-8 years or < 4’9” tallo Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Water safety, swimming lessons o Outdoor safety, supervision o Firearm safety o Sunburn prevention

Healtho Low fat milko Encourage fruits and vegetableso Brush teeth, see dentist o Encourage active play o < 20-30% of calories from dietary fat o < 10% of calories from saturated fat o < 300 mg of cholesterol per day

Social/Behavioralo Give choices o Encourage independenceo Praise good behavioro TV limits, read to childo Help child handle angry feelings and resolve conflicts with others o Family relationshipso Friends and playmates o Questions about sexo Pre-school, school readiness

Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo DTaP, IPV (4th dose on/after 4th bday), MMR, *Varicella (2 doses or hx of dz), Hep A o Influenza vaccineo V.I.S./Counselingo Chewable vitamins with iron o If BMI >85%, follow-up plan o Cholesterol –Fasting Lipid Profile (if at risk)_____ o Dental referral o Fluoride Varnish o Hgb if at risko Lead level if at risk o PPD if at risko 5 year Handout sheeto RTC at ______ years o Parent declination of treatment ______ o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation



* see separate form * Required for Kindergarten entry


Tennessee Chapter

®

5 Year Visit/Kindergarten Check-up



B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 9-11 years)Hearing Risk Assessment (7 and 9 yrs) — + Hearing screen (6, 8, 10 yrs) o Normal o AbnormalDate:______________________

Vision Risk Assessment (7 and 9 yrs) — +Vision screen (6, 8, 10 yrs) L near 20/ ______________ far 20/ ________ R near 20/ ______________ far 20/ ________ o Wears glasses, sees eye specialist

Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ Dental Risk Assessment (age 6 years) — + Lead Risk Assessment* — + (through age 6) TB Risk Assessment* — +



o Normal o AbnormalSchool Grade____________ Problems? o Yes o NoIf Yes, what? _______________________

Safetyo Buckle up! Ride in back seato Booster seat – rear seat – 4-8 years or < 4’9” tall

OR seat belt –rear seat over 8 years or > 4’9” tallo Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Water safety, swimming lessonso Firearm safetyo Sunburn preventionHealtho Low fat milk and snackso Encourage fruits and vegetableso Brush teeth, see dentisto Adequate sleepo Encourage sports, active playo Sports form completedo < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per daySocial/Behavioralo School adjustment, performanceo Sports and hobbieso Limit TV, computer games <2 hrs/dayo Give choiceso Encourage independenceo Set limits, provide consequenceso Parent supervises peer activitieso Privacy, personal hygieneo Puberty changes and questions about sexo Family relationshipso Friends and Schoolo Social media, safety settingso Dealing with strangers

Impressiono Well Childo Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo DTaP/Td/Tdap, IPV (4th dose on/after

4th bday), MMR, *Varicella (2 dosesor hx of dz), HPV

o Influenza vaccineo V.I.S./Counselingo Cholesterol –Fasting Lipid Profile

(if at risk 2-8 yrs)_____o Cholesterol - Non-fasting Lipid Profile

or Fasting Lipid Profile (once between 9and 11 years)________

o Lead level if at risko PPD if at risko Dental referral at age 6o Hgb (if + menarche or high risk every

year)__________o If BMI >85%, follow-up plano RTC at ______ yearso Handoutso Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlSpine --------------------- o nl o abnlExtremities -------------- o nl o abnlHips/Gait --------------- o nl o abnlSkin ---------------------- o nl o abnlNeuro --------------------- o nl o abnlGenitalia/Tanner Stage Female o Male o


* see separate form * Required for Kindergarten entry


Tennessee Chapter

®

6 to 10 Year Visit



B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M o Yes o No FH CVD heart disease <65 F o Yes o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 9-11 years)Hearing Risk Assessment (11 - 15 years) — +Vision Risk Assessment (11, 13 and 14 years) — + Vision Screen (12 and 15 years) L near 20/ ______________ far 20/ ________R near 20/ ______________ far 20/ ________o Wears glasses, sees eye specialist

Anemia Risk Assessment — + poverty ___ poor diet ____ chronic illness _____ menorrhagia ____ Alcohol/Drug Screen (11-21 years) — + TB Risk Assessment — + STI/HIV Risk Assessment (11-21 years) Hx of sexual activity — + Hx of IV drug use — + Depression Screening* (11-21 years) o Normal o AbnormalDevelopmental Surveillance o Yes o No Concerns? _____________


School Grade____________ Problems? o Yes o NoIf Yes, what? _______________________ __________________________________

Safetyo Buckle up!o Bike helmet, street safetyo Smoke detectors in homeo No smoking in homeo Swimming, water safetyo Firearm safetyo Sunburn preventionHealtho Low fat milk and snackso Healthy food choices, Ca intakeo Brush teeth, see dentisto < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per dayo Adequate sleepo Acneo Encourage sports, active playo Sports form attached o Yes o NoSocial/Behavioralo School adjustment, performanceo Sports and hobbieso Limit TV, computer gameso Give choiceso Encourage independenceo Set limits, provide consequenceso Managing stress, angero Say no to alcohol, drugs, tobaccoo Puberty changes and questions about sexo Periods (girls) LMP _______________o Family relationshipso Friends, boy/girl friendso Abstinence, birth control

Social/Behavioral (continued)o Social Mediao Sleep hygieneo + eating disorder screenImpressiono Well Child/Adolescento Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo *Tdap, MCV4, *Varicella (2 doses or hx

or dz), Hep B, HPV o Influenza vaccineo V.I.S./Counselingo RTC at ______ yearso Handoutso Cholesterol - Non-fasting Lipid Profile

or Fasting Lipid Profile (once between 9and 11 years)

o Cholesterol – Fasting Lipid Profile (12-16years) only if new risk factors in self or family

o Hgb (if + menarche or high risk everyyear)__________

o PPD if at risko STD screeningo Begin transition plano Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlExtremities -------------- o nl o abnlGenitalia/Tanner Stage Female o Male o

Musculoskeletal ExamShoulder/arm ----------- o nl o abnlElbow/foremarm ------- o nl o abnlWrist/hand/fingers ---- o nl o abnlHips/thigh --------------- o nl o abnlKnee ---------------------- o nl o abnlLeg/ankle ---------------- o nl o abnlFoot/toes ----------------- o nl o abnl


* see separate form * Required for 7th Grade entry


Tennessee Chapter

®

11 to 15 Year Visit



B/P: ________ / ________NutritionLow fat milk? o Yes o NoVariety of fruits, vegetables? o Yes o No Eats breakfast? o Yes o NoEats supper with family? o Yes o NoInterval History/New ProblemsChange in family history? o Yes o No Change in social history? o Yes o NoIf Yes, what? _________________________________________________________Are there new problems or illnesses since the last visit? o Yes o NoIf Yes, what? _______________________ __________________________________Dyslipidemia Risk Assessment — + FH CVD heart disease <55 M ____________o Yes _____________________________o NoFH CVD heart disease <65 F ____________o Yes _____________________________o NoFH cholesterol o Yes o NoBP > 90% ___ DM ___ inactive ____ passive smoke ____ Chronic illness ___ BMI > 95% ____ Dyslypidemia Screen ____(Once between 18-21 years)Hearing Risk Assessment (16 - 21 years) — +Vision Risk Assessment (16 - 21 years) — + o Wears glasses, sees eye specialistAnemia Risk Assessment* — + poverty ___ poor diet ____ chronic illness _____ menorrhagia ____ Alcohol/Drug Use — + Assessment*(11-21 years) Ethoh, drug or substance to get high — + TB Risk Assessment — + STI/HIV Risk Assessment (11-21 years) Hx of sexual activity — + Hx of IV drug use — + HIV Screen ____(Once between 16-18 years) Depression Screening* (11-21 years) o Normal o AbnormalDevelopmental Surveillance o Yes o No Concerns? _____________


School Grade____________ Problems? o Yes o NoIf Yes, what? _______________________ __________________________________

Safetyo Driving and automobile safetyo Bike helmet, safetyo Smoke detectors in homeo Swimming, water safetyo Firearm safetyo Sunburn prevention, tanning bedsHealtho Healthy food choices, Ca++ intakeo Concerns about weight, body imageo Periods (girls) LMP____________o < 20-30% of calories from dietary fato < 10% of calories from saturated fato < 300 mg of cholesterol per dayo Adequate sleepo Acneo Encourage sports, exerciseo Sports form attached o Yes o NoSocial/Behavioralo School adjustment, performanceo Plans for work/further educationo Tobacco useo Drug and alcohol useo Dealing with stress, angero Limit TV, computer time <2 hrs/dayo Friends and funo Boy or girl friends /dating safetyo Abstinence, birth controlo STDso Family relationships

Social/Behavioral (continued)o Social Mediao Sleep hygieneo Eating disorder screen — +Impressiono Well Adolescento Normal Growtho Normal Developmento ________________________________o ________________________________Plan/Referralso Immunizations current? o Yes o Noo Tdap, MCV4 Booster, Varicella, HPV, Hep Bo Influenza vaccineo V.I.S./Counselingo RTC at ______ yearso Handoutso Cholesterol – Non-fasting Lipid Profile if

at risk 16-17 years. Non-Fasting LipidProfile once between 18-21 years

o Hgb (if + menarche or high risk everyyear)__________

o Pap - 21 yearso STD screeningo HIV Screen (once between 16 and 18)o PPD if at risko Review transition plano Parent declination of treatment ______o Referrals _______________________o ________________________________o _______________________________________________ M.D. / P.N.P. / DO / PAPROV# ___________________________o See back for additional documentation

General ------------------ o nl o abnlHead ---------------------- o nl o abnlNeck ---------------------- o nl o abnlEyes ---------------------- o nl o abnlEars ---------------------- o nl o abnlNose ---------------------- o nl o abnlThroat/Mouth/Teeth -- o nl o abnlChest Breasts/Tanner Stage -- o nl o abnlLungs--------------------- o nl o abnlHeart --------------------- o nl o abnlAbdomen ---------------- o nl o abnlFemoral Pulses --------- o nl o abnlExtremities -------------- o nl o abnlGenitalia/Tanner Stage Female o Male o

Musculoskeletal ExamShoulder/arm ----------- o nl o abnlElbow/foremarm ------- o nl o abnlWrist/hand/fingers ---- o nl o abnlHips/thigh --------------- o nl o abnlKnee ---------------------- o nl o abnlLeg/ankle ---------------- o nl o abnlFoot/toes ----------------- o nl o abnl


* see separate form

Note: Bright Futures recommends screenings through age 21. TennCare Kids provides coverage for children birth until age 20 and ends when a member turns age 21. Any recommendation that mentions “21 years” as an end-date is not a TennCare Kids covered service.


Tennessee Chapter

®

16 to 20 Year Visit



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