MR #: __________________________ WELL CHILD/0 to 1 MONTH

NAME DOB ❏ M DRUG ALLERGIES ❏ 1st Visit

❏ F
❏ Periodic Visit

DATE/TIME INSURANCE ID # AGE WEIGHT HEIGHT HEAD CIRC.

❏ lb. % ❏ in. % ❏ in. %
YRS MOS
❏ kg. ❏ cm. ❏ cm.
ACCOMPANIED BY PHONE 1 PHONE 2 IF PULSE Ox TEMP RR P BP
INDICATED:

Birth History/Parent Concerns Physical Examination (Unclothed)

❏ Completed NL ABN

Pregnancy (medication, illnesses, drugs, ETOH) _________________________

❏ ❏ General Appearance _______________________________________________
________________________________________________________________ ❏ ❏ Head / Fontanelle _________________________________________________
________________________________________________________________ ❏ ❏ Eyes / Red Reflex _________________________________________________
Gestational age: ___________ BW: ___________ APGARS: _______________
❏ ❏ Ears ____________________________________________________________
Complications: ____________________________________________________ ❏ ❏ Nose ___________________________________________________________
________________________________________________________________ ❏ ❏ Mouth/Throat _____________________________________________________
❏ ❏ Lungs ___________________________________________________________
Social/Family History
❏ ❏ Heart / Pulses ____________________________________________________
❏ Completed ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
________________________________________________________________ ❏ ❏ Genitalia _________________________________________________________
________________________________________________________________ ❏ ❏ Extremities / Hips __________________________________________________

Child Care: ❏ Yes ❏ No Type: __________________________________ ❏ ❏ Back ____________________________________________________________

❏ ❏ Skin_____________________________________________________________
Review of Systems ❏ ❏ Neurologic _______________________________________________________
❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________ _______________________________________________________________________

_________________________________________________________________ Assessment and Plan

❏ Elimination Assessed ____________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Environment Assessed __________________________________________ ❏ Hearing Concern ❏ Prematurity ❏ Other:

❏ Sleep Patterns Assessed ________________________________________ Assessment: ____________________________________________________________

❏ Development Assessed: (Use Table on Back) ________________________ _______________________________________________________________________

OR ❏ DENVER DEVEL. II ADMINISTERED
OR ❏ OTHER TOOL ADMINISTERED: ________________________________
Comments:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Anticipatory Guidance Provided
❏ Topics discussed and/or handout given
SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding

Immunizations/Screens Referrals
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________ ❏ Referral Made: _______________________________________________________

Newborn Hearing Screening:❏ Pending ❏ Pass ❏ Fail F/U Next Visit: ___________________________________________________________

❏ Immunizations Reviewed: ❏ First HBV given Date:_________________ History and physical reviewed with resident at time of visit, agree with the diagnosis
of and treatment
Immunizations Ordered:
Provider Print Signature
❏ HBV

❏ Medical / Religious Exemptions: ___________________________________ Nurse Print Signature

Immunization Comments: ____________________________________________

_________________________________________________________________ Other Print Signature

Version 1.1 (5/06)

No. 1 of 7 ✔ or ❏
Instructions: If the action was taken or completed, the open box must be marked (❏ x ).
COPY FOR DC DOH
MR #: __________________________ WELL CHILD/0 to 1 MONTH
NAME DOB ❏ M DRUG ALLERGIES ❏ 1st Visit
❏ F
❏ Periodic Visit

DATE/TIME INSURANCE ID # AGE WEIGHT HEIGHT HEAD CIRC.

❏ lb. % ❏ in. % ❏ in. %
YRS MOS
❏ kg. ❏ cm. ❏ cm.
ACCOMPANIED BY PHONE 1 PHONE 2 IF PULSE Ox TEMP RR P BP
INDICATED:

Birth History/Parent Concerns Physical Examination (Unclothed)

❏ Completed NL ABN

Pregnancy (medication, illnesses, drugs, ETOH) _________________________

❏ ❏ General Appearance _______________________________________________
________________________________________________________________ ❏ ❏ Head / Fontanelle _________________________________________________
________________________________________________________________ ❏ ❏ Eyes / Red Reflex _________________________________________________
Gestational age: ___________ BW: ___________ APGARS: _______________
❏ ❏ Ears ____________________________________________________________
Complications: ____________________________________________________ ❏ ❏ Nose ___________________________________________________________
________________________________________________________________ ❏ ❏ Mouth/Throat _____________________________________________________
❏ ❏ Lungs ___________________________________________________________
Social/Family History
❏ ❏ Heart / Pulses ____________________________________________________
❏ Completed ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
________________________________________________________________ ❏ ❏ Genitalia _________________________________________________________
________________________________________________________________ ❏ ❏ Extremities / Hips __________________________________________________

Child Care: ❏ Yes ❏ No Type: __________________________________ ❏ ❏ Back ____________________________________________________________

❏ ❏ Skin_____________________________________________________________
Review of Systems ❏ ❏ Neurologic _______________________________________________________
❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________ _______________________________________________________________________

_________________________________________________________________ Assessment and Plan

❏ Elimination Assessed ____________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Environment Assessed __________________________________________ ❏ Hearing Concern ❏ Prematurity ❏ Other:

❏ Sleep Patterns Assessed ________________________________________ Assessment: ____________________________________________________________

❏ Development Assessed: (Use Table on Back) ________________________ _______________________________________________________________________

OR ❏ DENVER DEVEL. II ADMINISTERED
OR ❏ OTHER TOOL ADMINISTERED: ________________________________
Comments:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Anticipatory Guidance Provided
❏ Topics discussed and/or handout given
SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding

Immunizations/Screens Referrals
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________ ❏ Referral Made: _______________________________________________________

Newborn Hearing Screening:❏ Pending ❏ Pass ❏ Fail F/U Next Visit: ___________________________________________________________

❏ Immunizations Reviewed: ❏ First HBV given Date:_________________ History and physical reviewed with resident at time of visit, agree with the diagnosis
of and treatment
Immunizations Ordered:
Provider Print Signature
❏ HBV

❏ Medical / Religious Exemptions: ___________________________________ Nurse Print Signature

Immunization Comments: ____________________________________________

_________________________________________________________________ Other Print Signature

Version 1.1 (5/06)

No. 1 of 7 ✔ or ❏
Instructions: If the action was taken or completed, the open box must be marked (❏ x ).
 WELL CHILD/0 to 1 MONTH
ADDITIONAL COMMENTS: ________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

NURSING NOTES: PAIN? ❏ No ❏ Yes

Score ____________________
❏ Management: See Treatment Plan
Interpreter Used? ❏ Yes ❏ No Primary Language:________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
BEHAVIOR AND DEVELOPMENT
Age Gross Motor Fine Motor Communication Social
0 to 1 __ Lifts head when prone __ Follows object with __ Vocalizes __ Smiles
Month __ Equal Movements eyes __ Responds to stimuli spontaneously
__ Looks at face

Suggested age appropriate topics for anticipatory guidance:

■ NUTRITION ■ INFANT CARE ■ INJURY AND ILLNESS PREVENTION
• Breastfeeding • Skincare/bathing • Crib safety
• Formula • Thermometer use • Back to sleep
• No solid food • Good sleep habits • Child safety seat
(wait until 4-6 mos) ■ BEHAVIOR & DEVELOPMENT • Falls
• Elimination ■ PARENT-INFANT INTERACTION • Burns
• No honey • Parental depression • Water heater
• Review of WIC status • Talk/read/sing to baby • Smoke detectors
■ ORAL HEALTH • Holding/cuddling • Sun safety
• No bottle in crib • Temperament • Violence/guns
■ IMMUNIZATIONS EXPLAINED • Passive smoking
• Never shake baby

INSTRUCTIONS
✔ or ❏).
If the action was taken or completed, the open box must be marked (❏ x
If the child is enrolled in Medicaid, please be sure to print and sign your name in the space provided and fax or mail the completed form to:
HEALTHCHECK REGISTRY
POST OFFICE BOX 77498
WASHINGTON, DC 20013-7749
FAX: (202) 541-5907
For further information on HealthCheck or Bright Futures go to www.brightfutures.org/healthcheck.html