Download Well Child Care - School of Medicine

Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
1-3 WEEKS
INTERVIEW
Informant:
CC/concerns:
Perinatal Hx: (NSVD/forceps/vacuum/Csec)
G.A. _______wks
BW:
Complications:
Pertinent FHx:
Feeding (breast vs. iron fortified formula 3 oz./lb./d, 0.5 to 1
oz./d wt. gain; WIC?)
Sleep (Where? Safety)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
DEVELOPMENT:
Follows visually
Appears to respond to sound
rev. 6/08 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
EXAM
Ht.
%ile Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnl Findings
Skin: birthmarks, jaundice
Head
Eyes-Red reflex
ENT
Lungs
Heart
Abd-masses
Umbilicus
Fem. Pulse
Genitalia
Hip abduction
Neuro-tone, primitive
reflexes
ASSESSMENT
PLAN
Diagnostic & Therapeutic:
Newborn screening (if not done yet)
Help Me Grow Referral (if high risk home or
risks of developmental delay)
Immunizations:
Hepatitis B #1 (if not given in hospital)
%ile
Patient Education:
Always place on back to sleep to prevent SIDS
Avoid second-hand smoke
Abnormal findings
Avoid people with colds,etc...
Always place infant in car seat, backseat
backwards
Never leave baby alone with young siblings or
pets
Never leavebaby unattended except in crib
Set hot water heater less than 120 degree
Fahrenheit and test water before use
Test smoke detectors in the home
Dress infant in flame resistant nightwear
Normal crying, colicky babies, sleep cycles
discussed
Normal stooling, spitting, and sleep cycles
discussed
Safe bed and bedding discussed
Signs of illness/when to call discussed: fever,
poor eating, unusual irritability, significant
vomiting or diarrhea.
Sun exposure avoidance discussed
Water safety discussed. Never leave the child
alone near or in water.
Parents and caregivers should receive the Tdap
vaccine to prevent transmission of pertussis to
infants
Consider Vitamin D
No solids or juice until 4-6 months
Premies: multivitamin and Fe supplementation
(see guidelines)
Encourage holding, cuddling, talking to baby
Mom's self care / post-partum depression
Sibling rivalry
Avoid polycarbonate milk bottles
Avoid pesticides, products with solvents
WCC visit frequency protocol
Follow-up:
rev. 6/08 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
age 2 months
(consider earlier visit for imm.)
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
1 & 2 MONTHS
INTERVIEW
Informant:
CC/concerns:
Perinatal Hx: (NSVD/forceps/vacuum/Csec)
G.A. _______wks
BW:
Complications:
PMHx:
Meds:
Pertinent FHx:
Feeding (formula to 32 oz., vitamins in breast fed, no solids )
Sleep (Where? Safety)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
DEVELOPMENT (* > 90%)
Follows visually through range of 90 degrees
Lifts head momentarily
Social smile
EXAM
Ht.
e
%il Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes-Red
reflex
ENT
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
Nodes
Chest
Heart
Abdomen
Genitalia
Extremities
Hip abduction
Neuro
ASESSMENT/PLAN
Diagnostic & Therapeutic:
_____ Always in car seat-in back seat, backwards
Adequate bedding- firm mattress, snug to edges
(not soft surface), nothing hanging, if slats-less
_____
than 2 3/8 inch
_____
Immunizations:
DTaP #1 (Combos: DTaP + IPV + Hep B or
IPV #1
HIB + Hep B)
HIB #1
Hep B #2
PCV7 #1
Rotavirus #1
_____
_____
_____
Patient Education:
Parental smoking
Introduce solids 4-6 months
Vitamins in breast fed
Accident prevention (car seats, falls,
advise against walker, water temp <120°,
sharp and small objects, plastic bags)
Parents getting out / frustrations
Post-partum depression / family planning
Fever, acetaminophen dose
Child care / parent support groups
Smoke detectors / CO detectors (check batteries)
Radon test for basement; prevent mold
Shoes not necessary until walking
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
_____
_____
Hot water heater less than 120 degrees- test water
before use
Never leave alone in water/where can fall
Never leave alone with young siblings/ pets
Discuss signs of illness: fever, poor eating,
unusual irritability, significant vomiting or diarrhea
Discuss: normal-stooling, spitting,
sneezing/snorting
Avoid exposure to the sun
Parents and caregivers should receive the Tdap
vaccine to prevent transmission of pertussis to
_____
infants
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
4 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
Meds:
Feeding (solids?)
Sleep (Where? Through night? 2-3 naps, regular schedule established)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
DEVELOPMENT (* > 90%)
Gurgles, coos, babbles, or similar sounds
Follows parents movements by turning
head from one side to facing directly
forward
Follows parents movements by turning
head from one side almost all the way to
the other side
Lifts head off ground when lying prone
Lifts head to 45' off ground when lying
prone
Laughs out loud without being tickled or
touched
Plays with hands by touching them
together
Will follow parent's movements by
turning head all the way from one side to
the other
Lifts head to 90' off ground when lying
prone
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
%ile Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes - EOM
ENT-TMs
Nodes
Chest
Heart
Abdomen
Genitalia
Extremities
Pulses
Hip abduction
Neuro
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Help Me Grow Referral (if high risk home or
risks of developmental delay)
Immunizations:
DTaP #2 (Combos: DTaP + IPV + Hep B or
IPV #2
HIB + Hep B)
HIB #2
PCV7 #2
_____ Rotavirus #2
Hep B #2 (if not already done)
Patient Education:
Solids by next visit (cereal), avoid honey
Consider Vit. D if breast fed
Childproof home (small objects,
stair gate, tub safety, no walkers)
Thumb sucking common
Talk to baby, respond to vocalizations
Acetaminophen dose
Shoes not necessary until walking
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Always place on back to sleep to prevent SIDS
No smoking; check your smoke detectors
Avoid people with colds, etc.
Car seat issues discussed, including proper
placement in back seat, facing backwards
Correct preparation of iron fortified formula
discussed
Never leave baby alone with young siblings or
pets.
Never leave baby unattended, except in crib
Hot water heater less than 120 degrees.
Normal crying, stooling, spitting, sleep cycles
discussed.
Safe bed and bedding discussed.
Signs of illness/when to call discussed: fever,
poor eating, unusual irritability, significant
vomiting or diarrhea.
Avoid sun exposure.
Water safety discussed. Never leave the child
alone near or in water.
Parents and caregivers should receive the
Tdap vaccine to prevent transmission of
pertussis to infants
Follow-up:
2 months
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
6 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
Meds:
Feeding (cereal with iron, fruits, vegetables; formula 28 oz/d )
Sleep (schedules)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
Lead exposure risk factors: Live in or visit a house built before 1960 with peeling paint or recent renovation? Sibling/playmate
with elevated lead? Live with adult with job or hobby involving lead? Live near industry likely to release lead?
(If any yes answer, child is high risk and should get lead testing)
DEVELOPMENT (* > 90%)
Hold head upright and steady
When placed prone will lift chest off the
ground
Occasionally makes happy high-pitched
noises (not crying)
Rolls over from stomach->back and back>stomach
Smiles at inanimate objects when playing
alone
Seems to focus gaze on small (coin-sized)
objects
Will pick up toy if placed within reach
Can keep head from lagging when pulled
from supine to sitting
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
%ile
Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes Strab.
ENT
Chest
Heart
Abdomen
Back /
Hips
Genitals
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
ASSESSMENT/ PLAN
Diagnostic & Therapeutic:
Hct./Hgb. for low birth weight
Lead screen for high risk (see above)
Immunizations:
DTaP #3
(Combos: DTaP + IPV + Hep B or
HIB #3
HIB + Hep B)
IPV #3
PCV7 #3
_____ Rotavirus #3
Influenza #1 (2 doses 1 month
___ apart if first flu vaccine up until 8
y.o.)
Hep B #3
Patient Education:
Fluoride if bottled or well water w/o Fluoride
Bed bottles, propping / comfort objects
Distraction for discipline
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Night crying / bedtime routine
Shoes not necessary until walking
Get down on floor/check for hazards at baby's eye
__ level
Always use infant car seat, backseat backwards
__ until one year of age.
Keep toys with small parts or other objects;
__ balloons, plastic bags out of reach.
__ Hot water heater less than 120 degrees.
__ No smoking; check your smoke detectors.
__ Do not use walkers.
Place plastic plugs in sockets, avoid dangling
__ cords.
__ Never leave alone in water, watch pools, buckets.
Keep poisonous substances; medicines, cleaning
__ supplies away in high latched cabinets.
__ Install gates on stairs, lower crib mattress.
__ Start reading to your baby daily.
__ Avoid exposure to sun.
Poison Control (1-800-222-1222) sticker /
magnet available
Followup:
3 months
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
9 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
Meds:
Allergies:
Feeding (encourage breast feeding >1 year, cup, milk 24 oz/d, table foods )
Sleep (night wakening)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
Lead exposure risk factors: Live in or visit a house built before 1960 with peeling paint or recent renovation?
Sibling/playmate with elevated lead? Live with adult with job or hobby involving lead? Live near industry likely to
release lead? (If any yes answer, child is high risk and should get lead testing)
DEVELOPMENT (* > 90%)
Passes small objects from one hand to
the other
Will try to find objects after they're
removed from view
At times holds two objects, one in each
hand
Can bear some weight on legs when held
upright
Picks up small objects using a 'raking or
grabbing' motion with palm downward
Can sit unsupported for 60 seconds or
more
Will feed self a cookie or cracker
Seems to react to quiet noises
Will stretch with arms or body to reach a
toy
Makes 'mama' or 'dada' sounds
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
%ile Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes - Strab.
ENT
Chest
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
Heart
Abdomen
Back / Hips
Genitals
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Lead screen for high risk (see above)
Immunizations:
Influenza series (2 doses 1 month apart if first flu
vaccine up until 8 y.o.)
Catch up immunizations if not up to date
(3 DTaP, 3 HIB, 3 IPV, 3 PCV7, 3 Hep B)
Patient Education:
Autonomy, discipline vs. punishment, limits
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Buy shoes when walking
Avoid choke foods - small objects, popcorn,
peanuts, raisins
Poison Control (1-800-222-1222)
sticker/magnet available
Acetaminophen dose
Encourage vocalization & communication
Partner & sibling involvement
Get down on floor/check for hazards at
_____ baby's eye level
Always use infant car seat, backseat
_____ backwards until one year of age
Keep toys with small parts or other objects;
_____ balloons, plastic bags out of reach
_____ Hot water heater less than 120 degrees
_____ No smoking; check your smoke detectors
_____ Do not use walkers.
Place plastic plugs in sockets, avoid dangling
_____ cords
Never leave alone in water, watch pools,
_____ buckets
Keep poisonous substances; medicines,
cleaning supplies away in high latched
_____ cabinets
_____ Install gates on stairs, lower crib mattress.
_____ Start reading to your baby daily.
_____ Avoid exposure to sun
Follow-up:
3 months
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
12 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
Meds:
Allergies:
Pertinent FHx:
Feeding (switch to whole milk, eating habits, table foods, healthy food choices: 5-6 fruit, veg protions daily)
Sleep (separation problems)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
TB risk factors: contact with person with TB; prior + PPD; family member with HIV/AIDS; close contact with person born
outside US in high risk area and in US < 5 yrs; lived in high risk area; living in shelter; significant contact with person who
has been in jail outside of Cuyahoga County or used IV drugs. Test child with risk factor(s) using PPD every 2-3 years.
Can bang 2 small objects together to
make sounds
DEVELOPMENT (* > 90%)
Will play peek-a-boo (wait for parent to
re-appear)
Will hold on to objects hard enough
that it takes effort to get them back
Can stand holding on to furniture for
30sec or more
Refers to parent by saying 'mama,'
'dada' or equivalent
Can go from sitting to standing without
help
Uses 'pincer grasp' between thumb
and fingers to pick up small objects
Can tell parent from strangers
Can go from supine to sitting without
help
Tries to imitate spoken sounds (not
necessarily complete words)
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
%ile Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes-EOM, Strab.
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NT-Teeth
Chest
Heart
Abd-masses
Genitalia
Back
Ext.-Feet
Neuro
NAME
DATE OF BIRTH
EXAM DATE
_____ toothpaste
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Hct. / Hgb.
Lead screen (venous)
Sickle (if no Hgb electrophoresis report)
Consider PPD if high risk (SE Asian refugee,
HIV, known contact)
Immunizations:
PCV7 #4
_____ Dtap #4
Hep A #1
Influenza series
HIB #4 (postpone if healthy)
_____ MMR #1
Varicella #1 (if at least 12 months old)
Catch up: 3 Hep B, 3 IPV
_____
Re-examine hot water heater; temperature
should be below 120 degrees
_____
No smoking around baby; check your smoke
detectors
_____
Do not leave heavy objects or hot liquids near
edges of tables or counters
_____
_____
_____
Offer variety of soft table food, watch for
choking and allergies, no bottles in bed with
baby
_____
Watch for burns- irons, curling irons, hot
liquids
_____
Never leave your child alone in water; watch
pools, buckets
(extra Hep B in Combo OK to reduce # of shots)
Patient Education:
Discipline: No and distraction
Wean bottle at night, when teeth present
Close supervision
Avoid TV until age 3
ROR: Let child control the book
Discontinue pacifier if frequent OM
Feeding: If Fe formula, switch to whole milk, 3
meals and 2 snacks/day, encourage selffeeding, holding a cup
_____
_____
Have consistent routines; limit rules, but be
consistent; praise frequently; use distraction;
be gentle, but firm
Read to your child frequently
Get down on the floor and check for hazards
from a toddler's perspective
_____
Tooth cleaning, dental care, limit amount of
Follow-up:
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Have the Poison Control phone number
readily available: 1-800-222-1222
3 months
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
15 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
All:
Meds:
Pertinent FHx:
Feeding (3 meals/d, finger foods)
Sleep (1 nap)
Elimination:
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
DEVELOPMENT (* > 90%)
Can walk alone or holding on to furniture YesNo
Can play 'pat-a-cake' or wave 'bye-bye' without
help YesNo
Appropriately uses at least 3 words other than
'dada' and 'mama' YesNo
Can stand unsupported for 5 seconds YesNo
Can stand unsupported for 30 seconds YesNo
Can bend over to pick up an object on floor and
stand up again without support YesNo
Can indicate wants without crying/whining
(pointing, etc.) YesNo
Can walk across a large room without falling or
wobbling from side to side YesNo
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
e
%il Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes - Strab.
ENT
Chest
Heart
Abdomen
Back / Hips
Genitals
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
ASSESSMENT/PLAN
NAME
DATE OF BIRTH
EXAM DATE
Diagnostic & Therapeutic:
Help Me Grow Referral (if high risk home or
risks of developmental delay)
Immunizations:
Check if up to date: 3 IPV, 4 HIB, 4 PCV7,
4DTaP, MMR #1, Varicella #1, Hep A #1
3 Hep B, 2 influenza, Pb screen, Hgb/Hct
(extra Hep B in Combo OK to reduce # of shots)
(postpone HIB #4 if healthy)
Patient Education:
If uses bottle, wean by 18 mos.
Review readiness for toilet training
(child understands expectations, words)
Discontinue pacifier
Discipline
Play, talk, read, sing with baby
Mother's time-off
Acetaminophen dosage
Avoid arsenic exposure: seal CCA-preserved
(pressure treated) wood, wash hands after play
Get down on the floor and check for hazards from
a toddler's perspective
_____
_____
Switch to a front facing toddler car seat, still placed
in the back seat only
Tooth cleaning, dental care, limit amount of
toothpaste
Re-examine hot water heater; temperature should
be 120 degrees
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
_____
No smoking around baby; check your smoke
detectors
_____
Do not leave heavy objects or hot liquids near
edges of tables or counters
Feeding: If Fe formula, switch to whole milk, 3
meals and 2 snacks/day, encourage self-feeding,
_____
holding a cup
_____
_____
_____
Offer variety of soft table food, watch for choking
and allergies, no bottles in bed with baby
Watch for burns- irons, curling irons, hot liquids
Never leave your child alone in water; watch pools,
buckets
Have consistent routines; limit rules, but be
consistent; praise frequently; use distraction; be
_____
gentle, but firm
_____
Have the Poison Control phone number readily
available: 1-800-222-1222
Install gates on stairs; provide close supervision
_____ when your child is outside
Avoid exposure to the sun; use sunscreen when
_____ outdoors
3 months
Followup:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
18 MONTHS
INTERVIEW
Informant:
CC/concerns:
PMHx:
All:
Meds:
Pertinent FHx:
Feeding (Weaned? likes & dislikes, table foods, self-feeding, drinks from cup)
Sleep (0-2 naps, bedtime ritual, night fears)
Elimination (stool and urine pattern):
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
DEVELOPMENT (* > 90%)
If ball is rolled toward child, child will roll it
back (not hand it back)
Walks up steps
Can drink from a regular cup (not one with
a spout) without spilling
Vocalizes and gestures
Speaks 6-10 words
Laughs in response to others
Follows simple instructions
Can point to at least 1 part of body when
asked, without prompting
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
EXAM
Ht.
%ile Wt.
%ile HC
Parent-Child Interaction:
Normal
Abnormal findings
Skin
HEENT - TM's
Strab.
Nodes
Chest
Heart
Abdomen
Extremities
Signed ____________________________________
%ile
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Consider early intervention if delay in development
Help Me Grow Referral (if high risk home or
risks of developmental delay)
Autism Screening
Immunizations:
Hep A #2 (if 6 mo. from #1)
Influenza series
Check if up to date: MMR, 3 Hep B, 4 PCV7,
4 DTaP, 4 HIB, 3 IPV, varicella,
Pb screen up to date
(extra Hep B in Combo OK to reduce # of shots)
Patient
Education:
Accident prevention (play near street,
driveway, water, Pica, playground safety)
Thumb sucking, masturbation
Short family outings.
Appropriate toys, sharing toys
Always use car seat; helmet if passenger on a
bike.
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Watch choking foods and small objects
(nothing smaller than a toilet paper tube).
Watch child in tub, around
water/pools/buckets, "knowing how to swim"
does not make a child safe.
Watch for burns; mugs, pots, irons, curling
irons, outlets.
Keep poisons away; poison center number: 1800-222-1222
Watch for climbing, falls, keep mattress on
lowest rung.
Brush teeth with pea-sized amount of
toothpaste; no bottle in bed.
Praise frequently.
Negativism, tantrums discussed.
Appropriate signs and timing of potty training
discussed.
Fire, pet, traffic and gun safety discussed.
Read to your child daily, limit TV to less than 2
hours/day.
Follow-up:
6 months
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
2 YEARS
INTERVIEW
Informant:
PMHx
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (snacks, 16 oz. milk/d – 2% or less)
Sleep (1 nap, own bed)
Elimination (stool and urine pattern) Signs of habit forming readiness?
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
TB risk factors: contact with person with TB; prior + PPD; family member with HIV/AIDS; close contact with person born
outside US in high risk area and in US < 5 yrs; lived in high risk area; living in shelter; significant contact with person who
has been in jail outside of Cuyahoga County or used IV drugs. Test child with risk factor(s) using PPD every 2-3 years.
DEVELOPMENT:
Copies parent's actions, e.g. while doing housework
Can put one small (< 2") block on top of another without it falling
Can take > 4 steps backwards without losing balance, e.g. when pulling a toy
Can take off clothes, including pants and pullover shirts
Can walk up steps by self without holding onto the next stair
Feeds with spoon or fork without spilling much
Helps to pick up toys or carry dishes when asked
Can kick a small ball (e.g. tennis ball) forward without support
Speaks in 2-word sentences
Uses at least 50 words
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
EXAM
Ht.
%ile Wt.
%ile HC
BMI:
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes - Strab
ENT
Nodes
Chest
Heart
Abdomen
Genitalia
Back
Extremities
Neuro
ASSESSMENT
PLAN
Diagnostic & Therapeutic:
Hct. / Hgb. or CBC
Lead screen (capillary or venous)
Help Me Grow Referral (if high risk home or
risks of developmental delay)
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
%ile
Immunizations:
PPV if high risk (sickle cell, asplenia, HIV)
Influenza (2 dose if first time)
Check if 4 DPT, 4 HIB, 3 IPV, 3 Hep B,
1 MMR, 4 PCV7, 1 varicella, 2 Hep A
Patient Education:
Always use car seat; helmet if passenger on a
bike.
Always use sunscreen when outdoors.
Watch child in tub, around
water/pools/buckets, "knowing how to swim"
does not make a child safe.
Watch for burns; mugs, pots, irons, curling
irons, outlets.
Keep poisons away; poison center number: 1
No smoking, avoid secondhand smoke
exposure.
Use smoke detectors, check batteries
regularly.
Brush teeth with pea
Give frequent praise, give choices.
Negativism, tantrums discussed.
Appropriate signs and timing of potty training
discussed.
Fire, pet, traffic and gun safety discussed.
Read to your child daily, limit TV to less than 2
hours/day.
Move from crib to bed
Curiosity about sex, use correct terms
Transient speech dysfluency (2-4 yr.)
Peer play, "pretend" play, preschool?
Normal toddler behavior
Discipline - time out
Keep any pets healthy
Follow-up:
1 year
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
3 YEARS
INTERVIEW
Informant:
PMHx
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (Avoidance of junk food; low fat milk)
Sleep (1 nap)
Elimination (trained? - 85% day/60% night)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Preschool?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
TB risk factors: contact with person with TB; prior + PPD; family member with HIV/AIDS; close contact with person born outside US in
high risk area and in US < 5 yrs; lived in high risk area; living in shelter; significant contact with person who has been in jail outside of
Cuyahoga County or used IV drugs. Test child with risk factor(s) using PPD every 2-3 years.
DEVELOPMENT (* > 90%)
Child can stack 4 small (< 2")
blocks without them falling
Can identify at least 2 of pictures of
cat, bird, horse, dog, person
Throws ball overhand, straight,
toward parent's stomach or chest
from a distance of 5 feet
Adequately follows instructions: 'put
the paper on the floor; put the paper
on the chair; give the paper to me
Can put on own shoes
Can pedal a tricycle at least 10 feet
Converses in 2-3 sentences
Understandable to others 75% of
the time
Copies a drawing of a straight
vertical line
Can jump over paper placed on
floor (no running jump)
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
EXAM
Ht.
%ile Wt.
%ile HC
%ile
BP ________
Parent-Child Interaction:
BMI:
Normal
Abnormal findings
Skin
Head
Eyes - Strabismus
ENT
Nodes
Chest
Heart
Abdomen
Genitalia
Back
Extremities
Neuro
Hearing
Speech
ASSESSMENT/ PLAN
Diagnostic & Therapeutic:
Dental referral
Lead screen
Consider Hct. / Hgb.
Consider PPD if high risk
Immunizations:
PPV catch-up if high risk (sickle cell, asplenia,
HIV)
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Influenza (2 dose if first time)
Check if 4 DPT, 4 HIB, 3 IPV, 3 Hep B,
1 MMR, 4 PCV7, PCV 13 booster, 1 varicella,
2 Hep A
Patient Education:
Magical thinking, questions
Balanced diet, healthy food and snacks
Sharing, taking turns / siblings & playmates
Discipline, time-outs; praise good beh.
Allow to explore, show initiative, choices
Emergency Numbers (dial 911)
Always use car seat; helmet if passenger on a
bike.
Always use sunscreen when outdoors.
Watch child in tub, around
water/pools/buckets, "knowing how to swim"
does not make a child safe.
Watch for burns; mugs, pots, irons, curling
irons, outlets.
Keep poisons away; poison center number: 1800-222-1222
No smoking, avoid secondhand smoke
exposure.
Use smoke detectors, check batteries
regularly.
Brush teeth with pea-sized amount of
toothpaste; dental visit every 6 months.
Teach good pedestrian skills/traffic saftey.
Check play areas, equipment should not be
over 3 feet tall, should have energy absorbing
surfaces.
Talk about strangers, "good and bad
touches."
Discuss fire, pet and gun safety.
Read to your child daily, limit TV to less than 2
hours/day.
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
4 YEARS
INTERVIEW
Informant:
PMHx
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (manners; 5-6 portions fruits/ veg. daily; limit junk food, processed, high-fat food)
Sleep (nightmares, enjoyable bedtime ritual)
Elimination (trained? - 90% day/75% night)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Preschool?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
TB risk factors: contact with person with TB; prior + PPD; family member with HIV/AIDS; close contact with person born outside US in
high risk area and in US < 5 yrs; lived in high risk area; living in shelter; significant contact with person who has been in jail outside of
Cuyahoga County or used IV drugs. Test child with risk factor(s) using PPD every 2-3 years.
DEVELOPMENT (* > 90%)
Recognizes colors
Uses prepositions: on, in, under
Sings a song
Competent book handling
Can wash and dry hands without
help
Correctly adds 's' to words to make
them plural
Can balance on 1 foot for 2 seconds
or more given 3 chances
Can copy a picture of a circle
Can stack 8 small (< 2") blocks
without them falling Plays games
involving taking turns and following
rules (hide & seek, cops & robbers,
etc.)
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Can put on pants, shirt, dress, or
socks without help (except help with
snaps, buttons, and belts)
Can say full name
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
EXAM
%ile BP ________
Ht.
%ile Wt.
BMI:
Hearing: L ___ R___
Vision: L____ R____
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes
ENT
Nodes
Chest
Heart
Abdomen
Genitalia
Back
Extremities
Neuro
Vision
ASSESSMENT
School readiness: (takes turns, follows rules, separates)
PLAN
Diagnostic & Therapeutic:
Consider Hct. / Hgb.
Lead screen
Dental referral
Immunizations:
DTaP #5
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
IPV #4
MMR #2
Varicella #2
Check if 4 DPT, 4 HIB, 3 IPV, 3 Hep B, 1
MMR, 4 PCV7, PCV 13 booster, 1
varicella, 2 Hep A
Influenza (2 dose if first time)
Patient Education:
Teach address, telephone #, emergency #
Limits vs. independence, praise; time-out
Exploratory walks & trips, interacts with other
children
After school child care
Change from car seat to a booster at 40 lbs;
use booster up to 80 lbs and height of 4 ft. 9
inches.
Wear sunscreen, avoid sunburn.
Watch child in tub, around
water/pools/buckets, "knowing how to swim"
does not make a child safe.
Wear helmets when using bikes, scooters,
skates; use protective sports gear.
Keep poisons away; poison center number: 1800-222-1222
No smoking, avoid second hand smoke
exposure.
Use smoke detectors, check batteries
regularly.
Brush teeth with pea-sized amount of
toothpaste; dental visit every 6 months.
Teach good pedestrian skills/traffic saftey.
Check play areas, equipment should not be
over 3 feet tall, should have energy absorbing
surfaces.
Talk about strangers, "good and bad
touches."
Discuss fire, pet and gun safety.
Read to your child daily, limit TV to less than 3
hours/day.
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
5 YEARS
INTERVIEW
Informant:
PMHx
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (balanced diet, regular meals, snacks)
Sleep
Elimination (enuresis?)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
School/Pre-school?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
TB risk factors: contact with person with TB; prior + PPD; family member with HIV/AIDS; close contact with person born outside US in
high risk area and in US < 5 yrs; lived in high risk area; living in shelter; significant contact with person who has been in jail outside of
Cuyahoga County or used IV drugs. Test child with risk factor(s) using PPD every 2-3 years.
DEVELOPMENT (* > 90%)
Draws person with head, body, arms, legs
Prints first name
Plays with other children - understands
feelings of others
Can appropriately answer the following
questions: 'What do you do when you are
cold? Hungry? Tired?
Can fasten some buttons
Can balance on one foot for 6sec given 3
chances
Can identify the longer of 2 lines drawn on
paper, and can continue to identify longer
line when paper is turned 180'
Can copy a picture of a cross (+)
Can follow the following verbal commands
without gestures: 'Put this paper on the
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
floor...under the chair...in front of
you...behind you'
Stays calm when left with a stranger, e.g.
baby sitter
Can identify objects by their colors
Can hop on one foot 2 or more times
Can get dressed completely without help
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
EXAM
Ht._______ ____%ile Wt. ______ _____%ile BP ________
BMI:
Vision: L
R
Hearing: L
R
Parent-Child Interaction:
Normal
Abnormal findings
Skin
Head
Eyes
ENT
Nodes
Chest
Heart
Abdomen
Genitalia
Back
Extremities
Neuro
ASSESSMENT/ PLAN
Diagnostic & Therapeutic:
Optometry referral
Audiometry
Dental referral for sealants
Consider Lead screen
Immunizations:
Check if 2 varicella, 2 Hep A, 5 DTaP,
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
3 Hep B, 4 IPV, 2 MMR, 4PCV 7, PCV 13
booster
Influenza (2 dose if first time)
Patient Education:
School entry – tour school, meet teachers
Praise, encouragement, affection
Family rules, Right from wrong
Limits vs. independence
Learns address and phone number
Change from car seat to a booster at 40 lbs;
use booster up to 80 lbs and height of 4 ft. 9
inches.
If guns in home, keep locked up, ammunition
separate, use trigger locks.
Watch child in tub, around
water/pools/buckets, "knowing how to swim"
does not make a child safe.
Wear helmets when using bikes, scooters,
skates; use protective sports gear.
Get adequate sleep (8-10 hours/night),
bedtime at 7-8 pm.
Encourage regular physical activity, healthy
diet.
Brush teeth with pea-sized amount of
toothpaste; dental visit every 6 months.
Teach good pedestrian skills/traffic saftey.
Check play areas, equipment should not be
over 3 feet tall, should have energy absorbing
surfaces.
Talk about strangers, "good and bad
touches."
Discuss fire, pet and poisoning safety.
Read to your child daily, limit TV to less than 3
hours/day.
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
6-8 YEARS
INTERVIEW
Informant:
PMHx:
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (balanced diet - food choices; regular meals & snacks; breakfast; 600-1200 mg Calcium/day)
Sleep
Elimination (enuresis?)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
School performance?
School attendance?
Peer/family interaction?
Sports Participation:
Syncope with exercise?
CP with exercise?
Family hx of sudden cardiac disease?
Recurrent concussions?
Joint instability?
ROS:
Tb Risk Assessment:
DEVELOPMENT (* > 90%)
Ties shoelaces
Draws family and tells a story
Counts to 10
Knows right from left
Rides bicycle
Can draw picture of a person that
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
includes at least 3 parts, counting
paired parts, e.g. arms, as one
Had at least 6 parts on that same
picture
Can appropriately complete 2 of the
following sentences: 'If a horse is
big, a mouse is...'; 'If fire is hot, ice
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
is...'; 'If mother is a woman, dad is
a...'
Can catch a small ball (e.g. tennis
ball) using only hands
Can balance on one foot 11 seconds
or more given 3 chances
Can copy a picture of a square
Can appropriately complete all of the
following questions: 'What is a
spoon made of?'; 'What is a shoe
made of?'; 'What is a door made of?'
Can button and zip without
assistance?
Can cut and paste without
assistance?
Observes rules?
Plays cooperatively with others?
Able to read?
Writes in cursive lettering?
EXAM
Ht._______ ____%ile Wt. ______ _____%ile BP ________
Vision: L
R
BMI:
Hearing: L
Parent-Child
Interaction:
R
Normal
Abnormal findings
Skin
Head
Eyes
ENT - hearing
Nodes
Chest
Heart
Abdomen
Genitalia
Back
ASSESSMENT/ PLAN
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Diagnostic & Therapeutic:
Optometry referral
Dental referral
Consider cholesterol if Fam. Hx.
Consider lead screen
Immunizations:
Check if 2 varicella, 2 Hep A, 5 DTaP,
3 Hep B, 4 IPV, 2 MMR
Influenza (2 dose if first time)
Patient Education:
Maintain ideal weight; physical activity
Community and school programs
Rules- TV, chores, cleaning room
Spend active time w/child
Parental role model
Self-discipline, handling anger
Adult supervision / after school care
Home dental care
Daily reading
Always wear your seatbelt.
If guns in home, keep locked up, ammunition
separate, use trigger locks.
Water/pool safety: never leave child
unsupervised.
Always wear helmets when using bikes,
scooters, skates, ATVs; use protective sports
gear.
Get adequate sleep (8-10 hours/night).
Exercise regularly, eat a healthy diet.
You should have a dental visit every 6
months.
Wear sunscreen, avoid sunburn.
Traffic safety discussed.
Playground safety discussed.
Do not talk to strangers; "good" touches and
"bad" touches discussed.
Avoid secondhand smoke exposure.
Limit amount of TV/video/computer games to
less than 3 hours/day
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
9-11 YEARS
INTERVIEW
Informant:
PMHx:
Meds:
Allergies:
FHx:
CC/concerns:
Feeding (balanced diet, regular meals, breakfast)
Sleep
Elimination (enuresis?)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
School performance?
School attendance?
Peer/family interaction?
Sports Participation:
Syncope with exercise?
CP with exercise?
Family hx of sudden cardiac disease?
Recurrent concussions?
Joint instability?
ROS:
Tb Risk Assessment:
DEVELOPMENT (* > 90%)
Becoming self-reliant?
Forming an identity?
Language skills at adult level?
Problem solves?
Becoming self-reliant?
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
EXAM
Ht._______ ____%ile Wt. ______ _____%ile BP ________
Vision: L
R
BMI:
NAME
DATE OF BIRTH
EXAM DATE
4 IPV, 2 MMR, 3 Hep B
Influenza
HPV
Meningococcal (@ 11 y.o.)
Tdap booster (@ 11 y.o.)
Hearing: L
R
Parent-Child Interaction
Normal
Abnormal findings
Skin
Head
Eyes
ENT - hearing
Nodes
Chest
Heart
Abdomen
Genitalia, early puberty
Back - Scoliosis
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Optometry referral
Dental referral
Consider cholesterol if Fam. Hx.
Immunizations:
Check if 2 varicella, 2 Hep A, 5 DTaP,
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Patient Education:
Rules- TV, chores, cleaning room
Spend active time with child
Reading daily; hobbies
Parental role model
Tobacco, alcohol, drugs
Adult supervision; know child's friends
Not home-alone / after school care
Home dental care
Always wear your seatbelt.
If guns in home, keep locked up, ammunition
separate, use trigger locks.
Water/pool safety: never leave child
unsupervised.
Always wear helmets when using bikes,
scooters, skates, ATVs; use protective sports
gear.
Get adequate sleep (8-10 hours/night).
Exercise regularly, eat a healthy diet.
You should have a dental visit every 6
months.
Wear sunscreen, avoid sunburn.
Traffic safety discussed.
Playground safety discussed.
Do not talk to strangers; "good" touches and
"bad" touches discussed.
Avoid secondhand smoke exposure.
Limit amount of TV/video/computer games to
less than 3 hours/day
Follow-up:
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
12-18 YEARS
INTERVIEW
Informant:
PMHx:
Meds:
Allergies:
FHx:
CC/concerns:
Nutrition (well-balanced diet, healthy food choices)
Sleep
Elimination (enuresis?)
Social Screen:
Father in home?
Current child-care arrangements: in home primary caregiver?
Siblings?
Parental coping/self-care/supports?
Maternal hx/depression?
Drug/EtOH abuse in family?
2nd hand smoke exposure?
School performance?
School attendance?
Social interactions (family, friends, activities, talents)?
Sports Participation:
Syncope with exercise?
CP with exercise?
Family hx of sudden cardiac disease?
Recurrent concussions?
Joint instability?
Previous injury?
ROS:
Tb Risk Assessment:
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
NAME
DATE OF BIRTH
EXAM DATE
ANTICIPATORY GUIDANCE- PATIENT
Regular exercise, adequate sleep
Balanced diet, maintain ideal wt, MVI for
girls
Communication with family
Peer pressure - Do friends pressure you to
do things you don't want to?
Discuss sexuality (nocturnal emissions,
masturbation, erection, menarche, sexual
activity, sexually transmitted infections)
Testicular self-exams
Home, habits
Education, employment
Accident prevention/seatbelts, ambition,
activities, abuse
Drugs (tobacco, alcohol, illicit), diet, MVI
for girls, depression
Sex, suicide, sexual coercion
ANTICIPATORY GUIDANCEPARENT
Praise, encourage activities
Spend time as a family
Maintain comfortable communication
Sex education (contraception, STIs,
abstinence), values about sex - Home,
School
Preparation for menarche, wet dreams
Respect privacy
Allow age-appropriate decisions
Clearly stated rules for behavior
Participation in school activities
School work match future goals?
Reasonable expectations
Limit TV, computer, electronic games,
exposure to loud music
Observe for stress, nervousness, sadness
What makes you proud about him/her?
Encourage independence, responsibility
Dental visit every 6 months
EXAM
Ht._______ ____%ile Wt. ______ _____%ile BP ________
BMI:
Vision: L
R
Hearing: L
R
Normal
Abnormal findings
Skin
Head
Eyes
ENT
Nodes - goiter
Chest
Heart
Abdomen
Ext. genitalia
Back - Scoliosis
Neuro
Tanner Stage
ASSESSMENT/PLAN
Diagnostic & Therapeutic:
Optometry referral
Dental referral
Consider cholesterol if Fam. Hx.
MVI for girls
Immunizations:
Check if 2 varicella, 2 Hep A, 5 DTaP,
3 Hep B, 4 IPV, 2 MMR
Hep A series if not done yet
Influenza, Pneumovax if high risk
HPV
Tdap booster if not done
Meningococcal vaccine if not done
Follow-up:
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
Signed ____________________________________
Family Medicine Center
University Hospitals Case Medical Center
Well Child Care
rev. 1/10 © Univ. Fam. Med. Foundation
Jason Chao, MD,MS
NAME
DATE OF BIRTH
EXAM DATE
Signed ____________________________________