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PATIENT NAME ________________________ DATE ________ DOB _________

Nursing Assessment: Temp _______ DRUG ALLERGIES
Weight _______ Percentile _______ Length _______ Percentile ________
FOC _______ Percentile _______ _______

HISTORY DEVELOPMENT
Walks well alone Climbs furniture & stairs ______ Waves “Good-bye” Cooperates with dressing
Interval History: Parental Concerns: _______________________________________________
Follows 1-step command Points with index finger_______________________________________ Imitates housework Names family members
Says 3 to 4 words in addition to “mama”, “dada”
Sleep Pattern? _______________________________ Drinks from a cup Finds a hidden toy
Stools: Consistency/Frequency:__________________ Plays alone Recognizes body parts

PHYSICAL EXAM
Nutrition:
Continue whole milk and regular table foods
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ______Head ____________Fontanelle ______ EENT ______ Neck____ Chest ____________ Lungs _____________ Heart ______ ____________ Abdomen ________________ Genitalia ___________
Back/Spine ___________ Extremities _________ Hips _____________
Skin ______________ Neurologic ______________

Social History: Primary Caregiver ___________Persons present in household? _________
Any changes ?_________________ Immunodeficient household contacts? ____________ Day Care Center ? ________________________

Family Medical History: Family member with TB? __Child at Lead Exposure Risk? ___ ___

ANTICIPATORY GUIDANCE
Discontinue bottle if not already done Crib safety Baby bottle tooth decay
Decrease in appetite normal Milk and honey now okay No toys with small parts
No nuts or popcorn Rolling off high places No plastic bags / marbles
Childproof home Do not leave alone with sibling Syrup of Ipecac / Poisonings
Water temperature No Smoking in Home Acetaminophen after shots
Car seat (toddler car seat)/ Air bags Sun exposure / Sunscreen Water / Pool safety

ASSESSMENT PLAN

Immunizations: Follow-up visit:
HIB

15 MONTH Checkup
LEAD RISK ASSESSMENT QUESTIONAIRE
1. Does your child live in or regularly visit an older home built before 1960? Does the house have peeling or chipping paint?
2. Do you live in a house built before 1960 that is currently being renovated?
3. Have any of your children, their playmates, or your neighbor’s children had lead poisoning?
4. Does your child frequently come in contact with an adult who works with lead?
Examples: Construction, Welding, Pottery/Ceramics, Furniture refinishing, Stained glass industries
5. Do you live near a lead smelter or battery recycling plant?
6. Do you use home or folk remedies that may contain lead?
7. Do you live near a heavily traveled highway?
8. Does the plumbing in your home have lead piping or copper piping with lead joints?
· Low risk children are screened at ages 12 and 24 months by serum lead level.
· Any “yes” to questions above confers high risk and screening begins at age 6 months, and is repeated every 6 months
until two consecutive measurements are < 10 mcg/dl, or three are < 15 mcg/dl. Re-testing is then done in one year.
High risk children from 36 to 72 months of age without previous testing should have a serum lead level.
· Screening stops at 6 years of age unless other factors are present.

ADDITIONAL DIAGNOSTIC TESTS
• Hemoglobin/Hematocrit