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Child Well Visit

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| WELL CHILD EXAM INFANCY:1 WEEK VISIT | Authority: P.A. 116 of 1973Completion: RequiredConsequences of non-completion:Non-compliance of licensing rules. | Michigan Department of Human Services | Well Child Exam Date | | | Patient Name | DOB | Sex | Parent Name | | | | | Allergies | Current Medications | | | Prenatal/Family History | | Weight | Percentile | Length | Percentile | HC | Percentile | Temp. | Pulse | Resp. | BP (if risk) | | | % | | | % | | | % | | | | | Birth History | Birth Weight | Gestation | | Vaginal | Complications | | Yes | | | | | C-Section | | | No |

Interval History: | (Include injury/illness, visits to other health care providers, changes in family or home) | | Apnea | | Yes | | No | | Monitor | | Breast every | | hours | | Formula | | oz every | | hours | | With iron | | Yes | | No | Type or brand | | | City Water | | Well Water | Elimination | | Normal | | Abnormal | Sleep | | | Normal (2 – 4 hours) | | Abnormal | Additional area for comments on page 2 | WIC | | Yes | | No | Maternal Infant Health Program | | Yes | | No | Screening and Procedures | Neonatal Metabolic Screen in Chart | | Yes | | No | Test Date: | | | | Normal | | Pending | | Today | Hearing | | | Responds to Sounds | | Neonatal ABR or OAE results in chart | Developmental Surveillance | | | Social-Emotional | | Communicative | | Physical Development | | Cognitive | Psychosocial/Behavioral Assessment | | | Yes | | No | Screening for Abuse | | | Yes | | No | | | Screen If At Risk: | | | Vision-Parental observation/concerns | | Immunizations: | HepB Given in Hospital? | | Yes |

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