4 MONTH OLD EXAM
Wt______% Length______%
HC______% HR ___
Any parental concerns: ______
·How is he/she sleeping? Back/side/belly?
· Nutrition
°If breastfeeding: How often and how long is he/she breastfeeding?
°Any concerns re: breastfeeding?
°Using breast pump/milk storage?
°If formula fed: type of formula ______and oz. per feed ______
° Intro to solids? Y or N
·Elimination
°Does baby have >6 wet diapers/24 hrs?
Y or N
°Stooling daily? Y or N
· What new things is baby doing?
· What are your childcare arrangements?
· Has parenting become easier?
· Have you been feeling stressed? Who do you turn to at times like this?
PAST MEDICAL HISTORY
______
DEVELOPMENTAL MILESTONES
Coos/vocalizes/babbles?
Spontaneous laughter?
Rolls over from front to back?
Controls head well?
Able to comfort self (fall asleep without breast or bottle)?
ANTICIPATORY GUIDANCE
Sleep on back Safety: pets, rolling
Water temperature hot liquids
Know signs of illness
Aware of Shaken Baby Syndrome
Oral care Smoke free environment
Immunizations Rear facing car seat
Baby bottle tooth decay Encourage partner to care for infant Breast pump/milk storage
Family planning Bedtime routine
Do not microwave fluids
DATE:______
IMMUNIZATIONS COMPLETED
DTaP #1 Comvax#1
IPV#1 Prevnar #1
PHYSICAL EXAM
NL Abnl
General ______
Skin ______
Head ______
Eyes ______
Ears ______
Nose/mouth ______
Neck/clavicles ______
Lungs ______
Heart/pulses ______
Abdomen ______
Genitalia ______
Hips ______
Extremities ______
Reflexes ______
IMPRESSION
PLAN
FU at 6 mos
Tylenol ______
Immunizations:
DTaP #2 IPV#2 Prevnar #2
Comvax#2 (Hib/HepB)
Resident ______
(print) ______
Staff ______
(stamp) ______