Department of health services state of wisconsin

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Division of Health Care Access and Accountability

F-01068D (01/11)

Reprinted and adapted with permission from Memee K. Chun, M.D.


(See 2nd page for Anticipatory Guidance for 6 Month Visit)

Completion of this form is voluntary.

Patient Name


Date of Birth








Today’s Date


Accompanied by


Head Circumference


Parental Concerns




Feeding: Milk: Type _     _______________oz./ day _     ________

Juice _     _________ Water _     _____________ x /day

Vitamins _     ______ Fluoride _     _____ Iron      __Solids: Type and Meals/ Day      





Sleep: Patterns, Facilities, and Hours


Note – Present (+) or Absent (-) as Appropriate

(Cross off parts not examined or not applicable)






Skin: Color, texture, hair, scalp



Head and Face: Symmetry, Af size _     _ cms _     _





Eyes: Pupils, conjunctivae, EOM, red reflex



Ears & Nose: Canals, tympanic membranes, turbinates,

localization of sound



Mouth & throat: Tongue, pharynx, number of teeth (  )



Reaction to Previous Immunizations


Neck and Chest



Heart and Lungs: Rhythm, S1, S2, Murmur (    )



Abdomen & Spine: Contour, palpation



Family Routine with Baby


Extremities: Hips, tibiae, feet standing position



Genitourinary: Hernia, foreskin retraction, vagina



Parents’ Description of Baby’s Temperament


Neuromuscular: Tone, C2 – C12, reflexes, DTRs

Tonic neck (  ) Placing (   ) Palmar grasp (  )

Babinski (  ) Moro (  )



Problems Identified and Received


Describe abnormal findings.     

Physical and Emotional Status


Diet: Finger Foods, Cup, Start Wheat


Development Observation R = Reported O = Observed




NO* = not observed by parents or examiners.





Pulled to sitting, has no head lag

Anticipatory Guidance: Night Awakening, Bed Time Routine.

Fear of Strangers, Separation Anxiety.

Safety: Poisonings, Use of Syrup of Ipecac, Poison Control Phone Number. Crawling, Rolling, Reaching. Coffee Cups, Table Cloths. Pot Handles, Cupboards, Sockets & Cords, Glass Objects, Plants, Shoes, Teething, Walker





Sits alone





Bears some weight on legs





Stands holding on





Pulls to standing





Hands generally open





Passes toy from hand to hand


Drug Co. and Lot No.

Expiration Date





In sitting position, looks for toy








In sitting position, takes 2 cubes








Turns to voice








Imitates speech sounds








Mama & Dada nonspecific








Turns away from strangers (cries)








Puts objects in mouth

SIGNATURE — Provider

Date Signed






Grasps object and resists pull





Works towards object just out of reach





Plays simple repetitive game (e.g., pat-a-cake)

Parents’ Interactions with Baby O = Observed M = Mother

Return to clinic in _     __ months.



F= Father NO* = Not observed here



Makes eye contact with baby



Responds only when baby cries



Sits back during exam



Physically attempts to calm baby



Spontaneously identifies positive qualities



Responds to baby’s vocalization with a vocal response



Hovers over baby



Consoles baby who shows reservation of stranger

Other Observations     

Development and Parent-Child Interaction      


F-01068D (01/11) Page 2

Cup can be introduced with small amounts (1/2 - 1 ounce) of milk to be given with solids. Juice and water can be given as snacks and on warm days. The baby may or may not hold the cup, but the adult does most of the tipping and guiding. The hand to mouth reflex is more developed and solids can be offered to the baby for self-feeding. Stop pureed foods and introduce "Junior" foods or mashed table foods on a spoon. Self-feeding solids should be small enough to hold in the hand and not too small to be lost in the palm. It should dissolve in the mouth and be swallowed and not break into chunks which may get stuck since the baby does not chew the food at this time. Teething biscuits are hard but as the baby sucks they become very soft. This is made of flour and so wheat cereals can also be started now.
Anticipatory Guidance

Night awakening: after having slept for a long period (6-8 hours), the baby may now start crying at night again. The baby wants to be held, nursed, and may not go back to sleep for a couple of hours. The best policy is to make sure the baby is okay, not change the diaper unless the baby had a bowel movement in which case change the baby in a dim light and without vocal stimulation. The parent should try not to pick up the baby at all. After a few nights the baby will give up crying.

Bedtime routine is definitely a good idea. Example: bathe, feed, sing/tell story/read, and then place in bed before the baby is asleep. Then the parents should turn off the light and leave.
Fear of Strangers
Babies by now may recognize the caretakers and view everyone else as a stranger, including the doting grandparents. There are several reactions they can have to a stranger: 1) acceptance with only a glance to the parent, 2) anxiety and wanting the parents but adapting rapidly to the situation and, 3) panic at the sight and especially at the grasp of any stranger. This infant needs to stay with the parent, examines the stranger, and makes his own explorations and advances. If the strangers respond too vigorously, it will lead to more panic. Quiet or no response is more likely to lead to more bold advance by the baby and eventual adaptation to the stranger.
Separation Anxiety
This is expressed at about 6 months or later in some form by most babies. What they see exists and if not visible then no longer exists. Therefore, when the baby wakes at night and there is no parent, they cry with anxiety. Similarly during the day if Mom walks into another room the baby cries. The parents need to vocalize more so that the baby will recognize and find comfort in the voice, even without seeing the parent.
Syrup of Ipecac — Give one ounce bottle to the parent.

Discuss development of the hand-to-mouth motion, which will bring many non-edible objects into the mouth. Most will be non-toxic and too large to be swallowed. Some foods will cause choking and/or aspiration, e.g., carrot pieces, peanuts (also extremely dangerous because of lipid pneumonia) and other nuts, or celery pieces. Some non-foods can be as much trouble, such as safety pins, buttons, pins, nails, or bolts.

Some non-edibles are actually poisonous and prevention includes removing all these out of the child's reach. Treatment may include vomiting. As soon as the parent realizes the child has eaten a poisonous substance, the Poison Control or primary care health professional should be contacted for instructions. If vomiting is desired then the syrup of ipecac is available and ½ ounce can be given with as much fluids as possible. The parent should be warned that vomiting should occur 15-20 minutes (i.e., on the way to the hospital). The poisonous substance and the vomitus should be brought in and examined.

Crawling may start around 8 months and the baby may stand up holding onto furniture. Babies become very mobile and all objects up to about three feet are within their reach. Rolling to move around the room is another form of locomotion that the baby may use. A few infants will stand and cruise holding onto furniture. With increase in mobility, the parents need to cover empty sockets, remove cords or block them with pieces of large furniture or tape to the wall, table cloths may be pulled off. Remove all breakable objects and plants from the baby's reach. Coffee cups, pots, and pot handles must be deliberately put out of reach. The parents should use back burners on the stove as much as possible. When the oven is on, the baby should not be left alone for even a few seconds in the kitchen. This is the age when the playpen is really useful. If the parent has to leave the baby for a few seconds to answer the doorbell or telephone or get the laundry, then the baby should be placed in the playpen where there are a few special toys. The length of the stay in the playpen should never be longer than necessary.
Cupboards should be cleaned out and rearranged with the empty pots and pans, paper and plastic wares in the lower cabinets. Place breakables and cans above the counter and cleaning material in a locked cabinet or closet.
Car seats some car seats only hold babies up to 20 pounds and parents will have to be reminded to change models. If the baby has always been in a car seat then they will probably not fuss. If they are starting now, they will be unhappy but still less likely to come to harm.

Shoes are needed for protection against hot sidewalks, nails, bees, rocks, etc. Any shoe with a protective sole is okay as long as it is one centimeter longer and about ½ centimeter wider than the feet when bought and changed as soon as this space is filled out.

See four month visit.

If parents want to use a walker, they should beware of the dangers involved. The walker should have wide wheel base and stairs must be fenced off. The baby needs to be watched for falls!

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