Free None - Wisconsin

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

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

GENERAL PEDIATRIC CLINIC / PRE-SCHOOL VISIT
(See 2nd page for Anticipatory Guidance for Preschool) Completion of this form is voluntary.

Patient Name Accompanied by Urinalysis Vision R. / L. / Urine culture Color

Date of Birth

Age

Height

Weight BP Pulse

Today's Date /

Hearing

Gross

Audiogram

Parental Concerns

Adjustment to exam Activity

Diet and Eating Habits: Regular meals, snacks

Persistence ­ Attention Span Distractibility

Sleep: Behavior at bedtime, naps, nightmares, facilities

Speech and Language Dental Referral

Activities: Quiet, active

Sitter / Day Care / Nursery School: Name and hours

Toilet Training: Day, night

Parents' Description of Activities with the Child: Temperament and Discipline Used, General Mood, Reaction to New Situations, Intensity of Reactions, Persistence / Attention Span, Distractibility, and Peer Relationships.

Problems Identified and Reviewed

(Cross off parts not examined or not applicable) Part N Skin: Color, texture Head: Symmetry, scalp, hair Eyes, EOM, pupils, cornea, conjunctivae, fundi Ears: Pinnae, canals, tympanic membranes Nose: Nares and turbinates Mouth: Tongue, gums, number of teeth ( ) Throat: Pharynx, tonsils Neck: Movements, thyroid Nodes: Axillary, cervical, inguinal, submandibular Lungs Heart: Rhythm, S1, S2, murmur Abdomen: Contour, 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) Describe abnormal findings

Abn

Physical and Emotional Status

Diet

Anticipatory Guidance: Obedience, discipline, consistency of approach, independence, biting, kicking, safety: accidents, poisoning, pica. Dental and personal care. Sex identification, nursery school and television. Review temperature taking, aspirin or acetaminophin dosages, care of minor infections. Blood lead test as needed. Immunization Drug Co. & Lot No. Expiration Date DTaP IPV MMR

Parents' Interactions with Child: NO*. = Not Observed Here O. = Observed M = Mother F = Father O. NO* Activity Makes eye contact Touches child Hovers over child Spontaneously identifies positive qualities Limits activity by Verbal Command Limits activity by Physical Action Gives simple, short directions / explanations Reinforces behavior with approval and attention Terminates activity with some forewarning Allows child to separate and check back Allows child to answer for self Interrupts child's conversation Limits child's exuberance

Other Observations

______________________________ ______________
SIGNATURE ­ Provider
Return to clinic in _____ months.

Development and Parent-Child Interactions

0Date Signed

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

Anticipatory Guidance for Preschool Visit Page 2

Independence, which began at birth and became apparent at the time walking started, is now manifested in everything the child does. Self-care should be encouraged, and by kindergarten the child should be able to dress and undress without help except for a few ties, buttons and right versus left. Eating should be totally independent. Bathing and toileting need supervision, but the child should achieve some independence. In the process of learning self-care, fine motor coordination may parallel motivation or be slower than desired by parents and/or child. Independence to the child will include many activities, which potentially may be harmful to objects and/or child. The parents must set firm limits and demand obedience when the child might be harmed. They should set definite limits and consequences. This is the age when some parents complain that "everything is a battle" and cannot give specific examples. To help modify a behavior, the parents need to acknowledge which behavior is most troublesome. Then they can monitor the antecedent to that behavior, describe the behavior, e.g. kicking table, screams, hits mother, etc., and also write down the consequences-how the parents reacted, what they did and how the behavior terminated. Data from the motoring sheets will help assess the cause of the problem and make plans on how to decrease and maybe eliminate the problem. Starting with one problem often teaches the parents to handle other problems. Safety, Accidents and Poisoning Leading causes of mortality and morbidity in this age group. Poisoning peaks in the 2-3 year explorer. Parents should be reminded to keep poisons out of reach. Labeling a poisonous substance with Mr. Yuk with the child's help is good educational activity, but it still should be put out of reach. Plants are frequently poisonous and medicines should never be called a candy. As the child matures in their gross motor activities, they wander further away from home. A five-year-old will need to be taught how to cross the street, how to direct himself to school and return and how to avoid talking to or going with strangers. In the preschool years the seeds are sewn for this knowledge but the parent cannot trust the child to go out and play alone yet. Supervision is still necessary.

Sex identification becomes obvious to the child as they learn to compare what they see. A single child with a single parent of the same sex may not have the opportunity to make this comparison. In peer group playing, preschoolers do undress and compare themselves. This should be viewed by the parent as a learning experience, supplemented at home by books and simple explanations. Preschoolers are in the concrete stage of understanding and do not ask for long scientific explanations. Labeling by name and direct explanation of function suffices. If the child's questions are readily answered, more questions will come with more developed thinking. Masturbation is discovered and enjoyed by the preschooler. Many parents seeing the child masturbate become very disturbed. They need to know this is a normal activity for children. The child does need to learn that it is usually not a socially acceptable activity and the parent should interrupt the child if they do it in public but masturbation in itself will not harm the child. Dental Care includes brushing the teeth without or with a little toothpaste, by the child and at regular intervals by the parent. The preschooler who adjusts easily to a new situation can be taken to the dentist for exploration and a quick look at the teeth. The dentist chosen needs to be able to adjust how much can be done with this child's temperament. Several visits may be necessary before a thorough check and fluoride prophylaxis treatment is actually given. Preparing the child, as for the physician's visit, may be very helpful.