Free None - Wisconsin

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

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

GENERAL PEDIATRIC CLINIC / ELEMENTARY SCHOOL VIST
(See 2nd page for Anticipatory Guidance for Elementary School Visit)

Completion of this form is voluntary. Patient Name Accompanied by Urinalysis Vision R. / Urine culture L. / Color

Date of Birth

Age

Height

Weight BP Pulse

Today's Date /

Hearing

Gross

Audiogram

Parental Concerns

Adjustment to Clinic Visit Mood

Living Situation

Intensity of Reactions Speech & Language Dental Referral

School and Grade: Adjustment
Part (Cross off parts not examined or not applicable) N/A Abn
Skin: Color, texture Head: Symmetry, scalp, hair Eyes: EOM, pupils, cornea, conjunctivae, fundi Ears: Pinnae, canals, tympanic membranes Nose: Nares & turbinates Mouth: Tongue, gums, number of teeth ( ) Throat: Pharynx, tonsils Neck: Movements, thyroid Nodes: Axillary, cervical, inguinal, submandibular Check: Expansion, breast tissue Lungs: Heart: Rhythm, S1, S2, murmur Abdomen: Contour, LSK, mass Genitourinary: Vagina, testes, urethral orifice, hernia Neuromuscular: Equilibrium, motor strength, sensory, coordination, cranial nerves, DTRs, Babinski Spine: Posture, hip and shoulder levels Extremities: Gait, range of motion of joints Anus: Rectal Sexual Development: (Describe)

Extracurricular Activities: Hobbies, Sports

Eating Habits

General Health

Parent's Description of Child's Temperament Adjustments to Home, Environment, Attention Span, Distractibility, Peer Relationships

Problems Identified and Reviewed

Physical and Emotional Status

Describe abnormal findings Parents' Interactions with Child: NO* = Not Observed Here Obs = Observed M = Mother F = Father Activity Obs NO*
Makes eye contact Touches child Hovers over child Spontaneously identifies positive qualities Reassures child who is unsure of situation Limits activity by verbal command Limits activity by physical command Voice calm when talking to child Gives simple, short directions/explanations Reinforces behavior through approval & attention Terminates activity with some forewarning Allows child to answer for self Interrupts child's conversation Limits child's exuberance

Diet: Obesity Prevention, Dietary Needs, Habits, Snacks

Anticipatory Guidance: Consistency of approach, guidance, need for praise, independence, allowance, modeling of behavior, responsibilities & role in family, honesty & ownership, fears & fantasies, television., school responsibilities, punctuality, home work, sex education, literature for parents & child. Safety: Cars, bikes, guns, water. Dental Care:

_______________________________ ____________
SIGNATURE ­ Provider Return to clinic in ______ months. Date Signed

Other Observations Parent-Child Interactions

General Pediatric Clinic / Preschool visit F-1068K (07/08)

Anticipatory Guidance for Preschool Visit Page 2

Elementary ­ Anticipatory Guidance Modeling of behavior by the parents probably influences the child more than anything they can say. The parents must be consistent in whay they do and expect the child to do. Questions, limits, need to be explained in reasonable terms, and now that the child is beginning to be able to do abstract thinking, explanations of choices and consequences can be understood. Independence and responsibilities need to be nutured and gradually given according to the capabilities of the child. Some limits still need to be firmly set. The child still has fears and fantasies which may not have been resolved, but they should be distinguished from necessary fear of real danger. The younger school age child may still be in the stage of mixing fantasy and truth. Explanations rather than punishment may be more appropriate at this stage of development. The responsibility for school related activities should be gradually shifted from parent to child. Sex education may be offered in school but the parent should find out what is taught and what the child understands. If the parent cannot discuss the subject comfortably, then the health professional should offer books for the parents and/or child or talk directly with the child. Night ejaculation, masturbation, premenstrual vaginal discharge, as well as the secondary sex changes, can be discussed with the child during examination of the genitalia and breasts. Gynecomastia may cause problems, especially in an obese boy, and the child needs to be reassured of their sexual identity.

Safety Accidents lead all diseases as the cause of death in this age group. Talking directly to the child and often without having discussed the subject with the parent is probably most effective with child. Bicycles are owned and ridden by every child. Safety check of bikes, helmets and rules on the road should be strongly reinforced. Water safety, cars, boats, guns, etc., should be discussed if appropriate for this child. First Aid in the form of thorough cleaning of all wounds should be mentioned. Dental Care Dental care related to diet and brushing should be reinforced when checking the teeth. Remind the child that the permanent teeth have no good substitutes. Dental referral should be made.