Dr. MJ Bazos, MD
3 YEAR Checkup
PATIENT NAME __________________________ DATE ________ DOB _________
Nursing Assessment: Temp _______ DRUG ALLERGIES
Weight _______ Percentile _______ Length _______ Percentile ________
FOC _______ Percentile _______ _______
Runs well Balances on one foot ___ Dresses self Feeds Self
Bends over easily Walks upstairs alternating feet____
Interval History: Parental Concerns: ________________________________________
Toilet-trained Plays with others
Says more than 100 words Uses 2-3 word sentences
Sings parts of songs Uses pronouns & plurals
Sleep Pattern: _______________________ Understands simple time concepts
Stools: Consistency/Frequency:___________ Knows own gender Answers “where” questions
Follows simple commands Understandable by others

Continue whole milk and regular table foods
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ___Head _____ EENT __ Vision O.D. ____ O.L. ___ O.U. ____ 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 talking to strangers
Teach to swim Avoid machinery Helmets for tricycles
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