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Date: February 16, 2009
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State: Wisconsin
Category: Health Care
Author: DHCF
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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068I (07/08)

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

GENERAL PEDIATRIC CLINIC / 24 MONTH VISIT
(See 2nd page for Anticipatory Guidance for 24 Months) Completion of this form is voluntary. Patient Name Accompanied by Reaction to Examination Persistence / Attention Span Parental Concerns Activity Intensity Level Distractibility Words Spoken, Sentence Length, Speech Clarity Part Skin: Color, texture, hair, scalp Head & Face: Symmetry, AF size _____ cms _______ Eyes: Pupils, conjunctivae, EOM, red reflex Ears & Nose: Canals, timpanic membranes, turbinates Nose: Discharge Mouth: Gums, tongue, number 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 N Abn Date of Birth Age Height Weight Today's Date

Head Circumference

General Health

General Behavior: Behavior at meals

Sleeping

Toilet Training: Bowel, bladder, day, night

Peer & Social Opportunities

Parents' Description of Child's Temperament

Problems Identified and Reviewed

Development & Parent-Child Interactions

Physical and Emotional Status

Anticipatory Guidance: Diet, snacks, independence, limit setting, temper tantrums, peer companionship, sharing, taking turns, sleeping, crawling out of bed, night fears, naps, T.V., dental care. Safety: Car seat, street, play, pica, lead exposure.

Developmental Observations NO*. = Not Observed by parents or R. O. NO* examiners R. = Reported, O. = Observed G.M. Runs well Jumps with both legs together, in one place Balances on 1 foot for 1-2 seconds Kicks the ball forward Throws a ball overhand Walks up the steps Walks down the stairs Pedals a vehicle F.M. Scribbles with a pencil Copies a vertical line Copies a circle Makes a tower of four cubes Makes a tower of eight cubes Lang. Has many single words Combines two different words together Points to a named part of the body Names a picture Uses plurals Says own name P.S. Puts a toy under the table Puts a toy on the floor Gives a toy to the mother Puts on some clothing alone Uses spoons well, spilling very little Washes and dries hands alone Plays games with others Helps or mimics simple household tasks Parents' Interactions with Child NO* = Not Observed Here O. NO* O. = Observed M = Mother F = Father Spontaneously identifies child's positive qualities Limits activity by verbal command Limits activity by physical actions Gives simple short directions / explanations Voice calm when talking to child Reinforces behavior through approval and attention Terminates activity with some forewarning Interrupts temper tantrums vocally Interrupts temper tantrums physically Allows child to separate and check back

______________________________ ______________
SIGNATURE ­ Provider
Return to clinic in _____ months.
(Cross off parts not examined or not applicable)

Date Signed

General Pediatric Clinic / 24 month visit F-1068I (10/08)

Anticipatory Guidance for 24 month visit Page 2

Diet Snacks - appetites vary tremendously from child to child and from day to day. If the snacks are kept in the "healthy food" category and the child sits to eat the few bites they take at each meal, a pattern will be set up for healthy dietary habits later on. Food should not be used for rewards or punishment. Milk intake should be limited to two cups or less. Independence, limit setting and temper tantrums are closely related. As the child strives for independence, they constantly test the limits of their activities. It is the parents' responsibility to set and consistently enforce these limits. It is important to define these limits clearly and to apply them sparingly, in most cases only to actions that will endanger the child's health or life. The parents must ask, "Is it really important to stop this particular activity?" If the answer is "yes," then the parent must follow through consistently. If the answer is "no" then it is much better to say nothing and continue to observe the child, helping when needed. Temper tantrums are a developmental manifestation of the toddler's way of dealing with frustration when unable to perform desired actions. A temper tantrum occurs when 1) the child's actions are limited by the parents, or 2) the child is developmentally unable to perform them. The parents' consistency will terminate the former, and growth and development the latter. Peer companionship, sharing, and taking turns should be encouraged. If the child is one who resists new situations, the process will take longer and require a lot of patience on the part of the parents. Most children eventually adjust and will learn from this process.

Television Luckily, the attention span of most toddlers is too short to sit through a television show. Others will sit and not move and stop doing everything else. Special programs for preschoolers may still be too limited for the toddler. Dental Care In this stage of imitation, the toddler can have a toothbrush without toothpaste and be encouraged to brush once or twice daily. The parents should also do this for them regularly. Safety Car seat ­ A toddler who has always been in a car seat in a moving vehicle will have little trouble staying in one. Street-playing outside requires constant adult supervision unless there is a specifically fenced area with non-poisonous plants. A discussion of pica is pertinent since the child is still putting many objects in their mouth. It is important for the parent to teach edibles versus non-edibles and to review lead exposure.