Dr. MJ Bazos, MD
4 YEAR Checkup
PATIENT NAME __________________________ DATE ________ DOB _________
Nursing Assessment: Temp__________________ DRUG ALLERGIES
Weight _______ Percentile _______ Height _______ Percentile ________
Blood Pressure _______

Walks up and down stairs without assistance
Dresses and undresses Feeds self
Hops on one foot Throws ball overhand
Interval History: Parental Concerns: ___________________________
Toilet-trained Plays with others
Unlimited vocabulary Uses 4-5 word sentences
Sleep Pattern: _______________________ Knows own gender Answers “where” questions
Stools: Consistency/Frequency:_______ Knows own last name Uses past tense appropriately
Enjoys humor, jokes Copies shapes
Understands simple time concepts
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 / bikes
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: