Free None - Wisconsin

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

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

GENERAL PEDIATRIC CLINIC / 12 MONTH VISIT
(See 2nd page for Anticipatory Guidance for 12 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 Exploration Adaptability to Examiner

Feeding: Milk, type __________ Amt / day ______________ oz. Breast ____ Bottle ____ Cup _____ Fingers _____ Spoon _____ Solids and Meals / day

Distractibility (Cross off parts not examined or not applicable) Part Skin: Color, texture, hair, scalp Head and Face: Symmetry, AF Size _____ cms ______ Eyes: Pupils, conjunctivae, EOM, red reflex Ears and 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. N Abn

Sleeping: Night Naps Behavior at bedtime

Review of Family ­ Social and Health

Parents' Description of Baby's Temperament

Problems Identified and Reviewed

Physical and Emotional Status

Diet: Weaning, drop in appetite, table foods. Add citrus fruits. Anticipatory Guidance: Negativism, manipulative behavior, setting limits, consistency in approach, expectations on toilet training. Speech stimulation. Review of fever control and care of minor illnesses. Safety: Pot handles, stairs, gates, plants, PICA. Car seat: Temperature taking, lead exposure. TINE Test

Immunization HepB Hib IPV Varicella

Drug Co. and Lot No.

Expiration Date

_____________________________ _______________
SIGNATURE ­ Provider
Return to clinic in _____ months.

Date Signed

Developmental Observations NO*. = Not Observed by parents or R. O. NO* examiners R. = Reported, O. = Observed G.M. Stands holding on to furniture Walks holding on to furniture Stands alone briefly Stands alone well Walks alone Stoops and recovers without holding on F.M. Bangs cubes held in two hands Pincer grasp Scribbles spontaneously Lang. Vocalizes and communicates without words Mama and Dada ­ nonspecific Mama and Dada ­ specific More than two single words P.S. Plays repetitive games Plays ball with examiner Feeds self using fingers Drinks from cup with help Comforted by parent's voice Quiets at parent's touch Needs cuddling for reassurance Parents' Interactions with Baby NO* = Not observed Here O. NO* O. = Observed M = Mother F = Father Talks to the baby Responds only when the baby cries Allows baby to explore Sits back during exam Watches baby during visit Limits activity by physical actions Limits activity by verbal command Voice calm when talking to baby Reinforces behaviors through approval and attention Other Observations Development and Parent-Baby Interactions

General Pediatric Clinic / 12 month visit F-1068F (07/08)

Anticipatory Guidance for 12 Months Page 2

Diet Speech Stimulation Weaning ­ breast-feeding weaning actually may have started a few months back as the baby may have cut back to 3 nursings. The mother can gradually decrease the number of feedings, often leaving the night feeding to last. Some children will be so interested in the environment that they don't nurse completely and the milk will decrease so the whole process is spontaneous and painless. If the mother wants to stop all of a sudden, she will feel discomfort for a few days. Table foods ­ can be encouraged totally with cup, spoon, and fingers used for self-feeding. The appetite may drop automatically in some children. If allowed to feed themselves, and offered a good balanced diet, the children will lose their baby fat and maintain a more proportional weight to the height. Parents need a lot of reassurance at this time that the child will not starve. The poor weight gain is normal and the new body dimensions are healthy. Many parents will feed, give frequent snacks and use food for reward or bribe for the child's other demands. This can set up an eating problem such as obesity, poor diet, control of parents with food, etc. Sometimes, giving the parents the permission to use one vitamin per day will relieve their anxiety regarding health needs and, with a lot of reinforcement, they will let the child develop good eating habits. They should be told to call the vitamin a vitamin and not candy and warned that the child can be poisoned from too many vitamins. Anticipatory Guidance Manipulative behavior - a one-year-old can manipulate their parents with his eating or lack of it. They also can use crying, smiling or looking cute to manipulate parents. The parents have to realize that this behavior often exists. Negativism is usually not severe but if everything he touches is a "no-no", the child may mirror the behavior. Setting limits and consistency in approach is extremely important and useful for the child in learning discipline. Inconsistency confuses the child and no limits make them insecure. A pattern can be started at this age and carried through the toddler years so that the child can know their limits and be disciplined in later years when parental influencing is in conflict with peer pressure. Toilet Training Find out the degree of interest felt by the parents. Discuss the norms in the United States and the physiologic development of the child. If the parents are not interested, then postpone what follows until the next visit. If they want to start toilet training, the child needs to be able to sit and get up when they want to or stand and move away from the toilet freely. They need to know the bladder and bowel signals. They need to dislike the feeling of urine or stool in the diaper and also want to please the parents in putting all these skills together to get to the toilet in time to perform. Children vary in development of all of these above skills. Girls seem to dislike the soiled diapers more than the boys do. She shows this by coming to the parent and wanting the diapers changed as soon as soiled. A child often shows a recognition of bladder and bowel control function by stopping play or other activities for awhile. Around one year, children make all kinds of sounds. Speech consists of words put together with certain intonations. Language includes speech or expressive language and understanding through hearing or bodily motions which is receptive language. Receptive language has been developing since birth. Most parents will say, "they understand everything I say" and through body language the child is able to express themselves so that the parents also understand. Speech has to be taught. It is done by mimicking the parents. Adult speech is long and complicated. For the child to mimic the sentence structure, it should be grammatically correct with the proper intonations but shortened and the word labeling the object being discussed, repeated. This is called labeling. For example, "Here is a glass of milk" (as the parent gives the milk to the child) and then repeat "milk". Safety Car seats need to be reinforced even though the child may raise objections, especially if not consistently placed in the car seat. Pot handles should be turned in as they present temptation to reaching hands. Plants must be placed out of reach. Stair gates are used until the child can be consistent at sliding down or climbing up. PICA ­ the eating of non-edibles needs to be watched. Swallowed or aspirated objects can cause major medical problems in this second year of life. Lead Exposure Sources include ­ Lead based paint, gasoline, solder. Possible pathways include ­ air, drinking water, food. Lead based paint is the most common high dose source of lead in children. About 74% of privately owned, occupied housing units in the U.S. built before 1980 contain lead-based paint. (CDC, October 1991) Review fever control and care of minor illnesses, adjust antipyretic doses and warn about overdoing. The child needs to be told these are medicine and not candy.