PERIODIC SCREENING BIRTH THROUGH 5 YEARS Patient Name:

Family History Recent Medical History

DATE: Age:
Environmental Assessment

[ [ [ [ [ [ [ [

] No changes since last screen ] Allergy or Asthma _________________________ ] Diabetes ] Cancer ] Heart Disease ] Sickle Cell ] T.B. _________ ] Other:
(Please note family members relation to patient)

[ [ [ [ [

] No changes since last screen ] Major Illness ________________________

] Hospitalizations ____ ] Allergies ____________________________ ] Current Medications ____ ____ Neonatal Screen: Results requested: WNL Yes Repeated No

[ ] No changes since last screen

Water supply: Sewer: City Well None City Septic None

Smokers in home: ___________________ Developmental Assessment Pets in home: _______________________ Subjective Assessment WNL Suspect Objective Assessment WNL Suspect

Comments: _______________________________

HT. WT. Head Circ. (0-2yrs): Hct or Hgb: WNL UTD UTO Value: ___________

Blood Pressure (3yrs and up): Urine Dipstick: WNL UTD UTO Comments: No No No Lead: Drawn UTD UTO [ ] Not required at this time Yes Yes Yes No No No (Objective Assessment Must Be In Chart) Lead Poisoning Risk Assessment (Copy of screen must be in chart) Peeling paint in house, daycare etc. Yes No Relative with lead poison Yes No House built before 1960 Yes No Renovation Yes No Adult work in pottery or ceramics Yes No Live near battery recycling plant or lead Yes No Release industry Yes No Live near highway or heavy traffic Yes No Nutritional Assessment [ ] Formula

Vision Screening Subjective: any eye disorder Yes F.H.O. eye disorder Yes Wear glasses Yes

Objective: Visual acuity R20/ L20/ Muscle Balance Pass Fail (Objective screening begins at age 4)

Hearing Screen Subjective: response to voices Delayed speech development Recurrent O.M. Hearing 20 db HL 1000Hz 2000 Hz Right Ear Left Ear Abnormal (Describe)

4000Hz

Physical Exam

Normal (

[ ] Breast fed

Cranium /Face Hair / Scalp EENT Mouth / Teeth Skin / Lymph Nodes Heart Lungs Abdomen Genitalia Musculoskeletal System Extremities Nervous System
[ ] Immunizations current Explain * (Vaccine record must be in chart.) Immunization Status [ ]Off Schedule* [ ]Medically Contraindicated* [ ]Parental Refusal*

Easting Problems _____ Vitamins Supplements Yes No Growth Grid WNL See Grid (Growth Grid must be in chart) Dental Assessment Any Dental Disease Yes Oral Car e Appropriate Yes Comments:

No No

Impressions:

Name of Dentist ____ (Dental Visits are recommended by age 3) Anticipatory Guidance (mark those discussed) Nutrition/Diet Skin Care/Hygiene Oral/Dental Behavioral/Developmental Safety Parenting/Discipline Immunization Management School Status Toilet Training

Plan or Referral:

[ ] Interpretive Conference Conducted

Key: UTD-Up To Date; UTO-Unable to Obtain; WNL-Within Normal Limits FHO-Family History of

Signature:

PERIODIC SCREENING BIRTH THROUGH 5 YEARS Patient Name:

DATE: Age:

Key: UTD-Up To Date; UTO-Unable to Obtain; WNL-Within Normal Limits FHO-Family History of

Signature: