Physician's Well Child Exam Form 4 Months

WELL CHILD EXAM - INFANCY: 4 MONTHS DATE
(Meets EPSDT Guidelines)
INFANCY: 4 MONTHS
CHILD'S NAME BROUGHT IN BY: DATE OF BIRTH
ALLERGIES CURRENT MEDICATIONS

PARENT TO COMPLETE
ABOUT THE CHILD
ILLNESSES/ACCIDENTS/PROBLEMS/CONCERNS SINCE LAST VISIT TODAY I HAVE A QUESTION ABOUT:
YES NO YES NO
My baby is sleeping well. My baby reaches for objects and can hold them.
My baby is eating and growing well. My baby rolls or tries to roll over from tummy to back.
It is easy to tell what my baby wants. My baby can see and hear. Eyes don't cross.
I do not have frequent times of sadness.

WEIGHT KG./OZ. PERCENTILE HEIGHT CM/IN. PERCENTILE HEAD CIR. PERCENTILE
Diet
Elimination
Review of systems Review of family history
Sleep
Review Immunization Record Other:
Screening: Health Education: (Check all discussed/handouts given)
N A
Hearing Family Planning Safety Sleeping on back
Vision Development Crib Safety Shaken Baby Syndrome
Development: Circle area of concern
Infant Bond Feeding Fever
Adaptive/Cognitive Language/Communication
Gross Motor Social/Emotional Fine Motor Passive Smoke No bottle in bed Child care
Behavior Appropriate Car Seat Maternal Depression
Mental Health
Other:
Physical: Assessment/Plan:
N A N A
General appearance Chest
Skin Lungs
Head/Fontanelle Cardiovascular/Pulses
Eyes (Cover/Uncover) Abdomen
Ears Genitalia
Nose Spine
Oropharynx Extremities/ Hips
Neck Neurologic
Nodes
Describe abnormal findings and comments:
IMMUNIZATIONS GIVEN
REFERRALS
HEALTH PROVIDER NAME

NEXT VISIT: 6 MONTHS OF AGE
HEALTH PROVIDER SIGNATURE HEALTH PROVIDER ADDRESS
DSHS 13-683B(X) (REV. 08/2004) - TRANSLATED SEE DICTATION

DISTRIBUTION: White - Physician Yellow - Parent/Guardian
INFANCY: 4 MONTHS
Your Baby's Health at 4 Months
Milestones Health Tips

Ways your baby is developing between 4 Regular checkups are a great time to ask the
and 6 months of age. doctor or nurse questions about your baby's
health and development. Make a list before you
Holds head up while lying on tummy. go for the checkup. Bring your baby's
Squeals, laughs, smiles. immunization history card with you to checkups.
Your baby can get immunizations even when he
Rolls over from front to back.
has a mild cold or diarrhea or is taking
Holds rattle, tries to put it in mouth. antibiotics. Immunizations will not make these
illnesses worse.
Tries to pass toys from one hand to the
other. At this age your baby gets all the nutrition she
needs from breast milk or formula. If you are
Recognizes parent's voice and face. breast feeding, try to keep it up through at least
Learns to sit upright, with support at first. the first year. Wait to give your baby cereal or
other solid foods until at least 5-6 months of age.
You help your baby learn new skills by
playing with her. Check your baby's vision and hearing. Watch to
see if her eyes follow moving objects. Notice if
she turns toward loud or unexpected sounds.
For Help or More Information
Continue putting your baby to sleep on his back.
For help finding childcare: Washington Keep soft bedding and stuffed toys out of his crib
State Child Care Resource and Referral for the first year. Make sure other caregivers do
Network, 1-800-446-1114. this also.
Child health and development

information: CHILD Profile website: Parenting Tips
www.childprofile.org. Sing, talk, and play with your baby every day.
Look at your baby and repeat the sounds he
CHILD Profile parent mailings: Healthy
makes.
Mothers, Healthy Babies Information and
Referral Line, Put your baby on her tummy to play on the floor.
1-800-322-2588 (voice) or Put toys near her so she can reach for them.
1-800-833-6388 (TTY Relay); ask to be
added to the mailing list if you are not If you have any concerns about your baby's
getting mailings now. development, ask your baby's doctor or nurse or
call Healthy Mothers, Healthy Babies.
Parenting Skills or Support: Family Help Safety Tips
line, 1-800-932-HOPE (4673), Family
Resources Northwest, 1-888-746-9568, Always keep one hand on your baby when she is
Local Community College Classes on a bed, sofa, or changing table so she does
not roll off.
Continue to use a rear-facing car seat on every

ride. Buckle your baby up in the back seat.
DSHS 13-683B(X) (REV. 08/2004)

Guidance to Physicians and Nurse Practitioners for Infancy (4 months)
The following highlight EPSDT screens where practitioners often have questions. They
are not comprehensive guidelines.
Hearing Screen
Use clinical judgment.
Developmental Milestones
Always ask about and follow-up on parent concerns about development or behavior. You may use the
following screening list, or use the Ages and Stages Questionnaire, the Denver II, or the ELMS2 (a
language screen).
Yes No
Holds head up to 90 degrees.
Laughs.
Follows past mid line.
No persistent fist clenching.
Instructions for developmental milestones: At least 90% of infants should achieve the underlined
milestones by this age. If you have checked "no" on even one of the underlined items, refer the infant for
a formal developmental assessment.
Notes: Immunization schedules are from the Advisory Committee on Immunization Practice of the U.S. Centers for Disease
Control or Prevention. Parents and providers may call Healthy Mothers, Healthy Babies (1-800-322-2588) with questions
or concerns on childhood development.
DSHS 13-683B(X) (REV. 08/2004)

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WELL CHILD EXAM - INFANCY: 4 MONTHS DATE

(Meets EPSDT Guidelines)

ALLERGIES CURRENT MEDICATIONS

ILLNESSES/ACCIDENTS/PROBLEMS/CONCERNS SINCE LAST VISIT TODAY I HAVE A QUESTION ABOUT:

I do not have frequent times of sadness.

HEALTH PROVIDER NAME

HEALTH PROVIDER SIGNATURE HEALTH PROVIDER ADDRESS

DSHS 13-683B(X) (REV. 08/2004) - TRANSLATED SEE DICTATION

Milestones Health Tips

Child health and development

Continue to use a rear-facing car seat on every

DSHS 13-683B(X) (REV. 08/2004)

Use clinical judgment.

DSHS 13-683B(X) (REV. 08/2004)

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