Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068G (07/08)

STATE OF WISCONSIN Reprinted and adapted with permission from Memee K. Chun, M.D.

GENERAL PEDIATRIC CLINIC / 15 MONTH VISIT
(See 2nd page for Anticipatory Guidance for 15-Months) Completion of this form is voluntary.

Patient Name Accompanied by
Parental Concerns

Date of Birth

Age

Height

Weight

Today's Date

Head Circumference
Activity Adaptability to Exam

Words Spoken Rating Habits: Milk _________________ oz. / day Diet

(Cross off parts not examined or not applicable)
Part N Abn
Skin: Color, texture, hair, scalp Head & Face: Symmetry, AF size ____ cms ___ _ Eyes: Pupils, conjunctivae, EOM, red reflex Ears & Nose: Canals, tympanic membranes, turbinates Nose: Discharge Mouth: Gums, tongue, # of teeth ( ) Nodes: Cervical, inguinal Lungs Heart: Rhythm, S1, S2, murmur Abdomen: Contour, masses, hernia Genitalia: Vaginal opening, testes ( ) ( ) Extremities: Range of motion, stance Neuromuscular: Tone strength, equilibrium, coordination, gait, DTRs Describe Abnormal Findings.

Behavior at meals Sleeping

Activities: Quiet and active

Parents' Description of Child's Temperament

Problems Identified and Reviewed

Developmental Observations NO*. = Not Observed by parents or R. O. NO examiners R. = Reported, O. = Observed
G.M. Physical and Emotional Status P.M. Lang. Diet: Pickiness, introducing new foods Anticipatory Guidance: Obedience, negativism, temper tantrums. Sibling rivalry. Expectations on toilet training and speech. Safety: Climbing, stove, water, poisons, plants, street, lead exposure. P.S. Walks alone Stoops and recovers Walks backwards Walks up steps with help Scribbles with a pencil Makes a tower of 2 cubes Mama & Dada clear & appropriate 2+ other single words Points to a named part of the body Removes a piece of clothing Drinks from a cup alone Uses spoon with spilling Explores by touching new objects Comforted by physical contact with parents

Parents' Interactions with child NO* = Not observed Here O. NO* O. = Observed M = Mother F = Father
Immunization DTaP MMR PCV Drug Co. and Lot. No. Expiration Date Hovers over child Spontaneously identifies positive qualities Consoles child when showing reservations of strangers Limits activity by verbal command Limits activity by physical restraint Gives simple, short directions / explanations Ignores "temper tantrum" Allows child to separate and check back

Other Observations

_____________________________ ______________
SIGNATURE ­ Provider
Return to clinic in _____ months.

Development and Parent-Child Interactions

Date Signed

General Pediatric Clinic ­ 15-Month Visit F-1068G (07/08)

Anticipatory Guidance Page 2

Diet

Speech, Labeling See "12 Month" Health Supervision. The child should be using the intonations of their language and have several single words. Again, parents have to pick up these words and reinforce the child, each time they say "ma" the mother should respond. Comprehension is ahead of speech and the child can understand short sentences, the meaning of "no" and several directions. Safety Do not allow the child to climb up near the stove or touch the stove. The pot handles should be turned in and parents urged to use back burners. All poisons should be out of reach, especially medicines which may have to be locked up as the gross motor skills of climbing continues to improve. If the child goes toward the street, the parents need the emergency "NO" and on reaching the child, they should scold and bodily stop and remove the child from the direction of their travels. This may have to be repeated many times whenever the child is outside. Taking the child to their room may not be interpreted correctly by the child since the street is out of sight and thus out of mind. MMR ­ the parents should be aware of the medical and legal reasons for giving these vaccines. The parents do have the ultimate responsibility and choice for their child although the health professional may greatly influence this choice. Lead Exposure See 12-Month Form .

Pickiness is common. When given other than a favorite food, the child will not eat but will pick at the food and if not allowed to leave until the plate is empty, the meal may take a long time or, more likely at this age, end with a crying child and a plate on the floor. If the child is really hungry, they will eat. With all the snacks children receive, they may not know the feeling of hunger. It will not hurt a child to skip a meal rather than being forced to eat. Introducing new foods ­ The ease with which the child accepts new foods depends upon the child's temperament. The one who reacts strongly against anything new will refuse, while the one who accepts new situations easily will eat if hungry. Both extremes should still be offered new foods but not forced to accept it. Anticipatory Guidance Negativism ­ this is usually mild at this stage with a few temper tantrums, which are easily distracted or easily handled by ignoring. It is good to discuss these briefly so that if the child should exhibit any negative behaviors, the parents can react appropriately. Sibling rivalry is usually exhibited by an older sib towards this toddler who is becoming a more demanding person and explores into the territory and belongings of the older child. If there is a newborn, this child is more likely to ignore the baby and demand their usual share of attention. The baby becomes part of the total environment to be explored and conquered. Similarly, a puppy or kitten is not an animal but part of the environment. Rough treatment of a puppy or baby is no different than what the toddler does to the book or ball. Look, touch, bite, sit on and toss away are ways a toddler explores the world. Obedience If the child has had limits set for them for the past 3-6 months, they know the parents will prevent some activities. They will continue to test the parents for their consistency but is more likely to obey if this consistency is exhibited. Expectations on Toilet Training See "12 Month" Health Supervision A girl may become interested enough to sit on the toilet at 15 months. A few actually know the signals and will in turn signal to the parent. Most become aware of soiled diapers and want to be changed. These girls may be placed on the toilet if there is regular time for the bowel movement. If the child is dry after a nap, then again, sitting on the toilet may catch the urine. The parents have to know the child's needs and have time to act immediately. Positive reinforcement in the form of praise will lead to repeat performance. Boys are not usually ready for toilet training at this age.