Dr. MJ Bazos, MD
2 YEAR Checkup
PATIENT NAME __________________________DATE ________ DOB _________

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

Pretends to read Does NOT share ____Walks up and down stairs alone Helps undress __
Uses spoon well Unzips zipper
Interval History: Parental Concerns: ________________________________
Follows 2-step command Identifies body parts
Toilet-training readiness Repeats what he/she hears
Says 50 to 100 words Uses 2-3 word phrases
Sleep Pattern: _________________________ Uses “me” appropriately Listens to stories
Stools: Consistency/Frequency__________________ Communicates feelings with gestures

Continue whole milk and regular table foods
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ___Head _____Fontanelle (should be closed)___ 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? ___ ___

Age - appropriate car seat Toddler bed Life vests when boating
Remove guns from house or lock up Regular diet No toys with small parts
No nuts or popcorn Avoid machinery No plastic bags / marbles
Childproof home Do not leave alone with sibling Syrup of Ipecac / Poisonings
Water temperature No smoking in home Discipline
Behavior problems Sun exposure / Sunscreen Water / Pool safety
Immunizations: Follow-up visit:
Hepatitis A