Well-Child Visit: 18 months Age mo c g’s name

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 Hx/Nutr/Devel

 Unclothed PE

 Labs

Health Educ

 Vision Screen

 Hearing Screen

 Immunizations

 Dental Referral

Well-Child Visit: 18 months Age______mo


G’s name: © Kevin Marks MD, 2012; Last Revised 2-22-2012

o Mom o Grandparent

Who is at the WCV? o Dad o Foster parent

o Sibling(s) o Other Caregiver

Health or growth concerns?




Interval Hx? _____

Breastfeeding o Yes o No

Cow’s milk? o Yes o No Whole or 2%? oz/day

Fe-rich cereal 2x qd? o Yes o No

Meats, fish, eggs, soy? o Yes o No

Vegetables, fruits? o Yes o No

Age-appropriate finger foods? o Yes o No Fruit juice, sugars? o Yes o No

Elimination concerns? o Yes o No ____________________


__________________________________________________ General developmental & ASD screenings (per AAP)

Administered: o ASQ o PEDS o PEDS:DM

Interpretation: o Typical/ observe o Atypical/ action needed

Domains: o expr. lang. o recept. lang. o cognitive

of concern o fine motor o gross motor o SE/ behavior

o self-help/ adaptive o other

Administered: o M-CHAT circle if: ( + ) or ( - ) o Other

Circle if: No bottle in bed ; Brushing; Fluoride

o Referred to dentist

o Fluoride varnish + handout


Updated in Problem List / EMR



Tobacco exposure? o Yes o No DV? oYes o No

o Cap Hemogram or HemoCue (If Hgb<11 or if high-risk for iron defic. then venipuncture CBC, ferritin, CRP)

o Blood lead level

o TB Skin Test if at risk per TB questionnaire

Cover test: o No motion

Corneal light reflex: o Symmetric

Hearing: o Turns to voice o Startles

Vitals & Growth Parameters

T C/F ax/rect/tymp P R BP /

HC cm ( %) Length cm ( %)

Wt kg ( ___ %) wt / ht ratio ____ %










Parent-Child Interaction


Growth: o typical o obese o overweight o underweight/ FTT

Development & Behavior: see above

Other: see EMR problem list




18 mo WCV handout (Bright Futures: Early Childhood)

ROR book & literacy counseling

o “Healthy Habits” / obesity prevention handout + counseling

o EI referral & care coordination phone #

o Positive parenting support group or counseling

o Refer for multi-speciality dev-behav. evaluation

o Fluoride 0.25mg + MTV w/ iron & Vit D 600 IU PO daily

  • Praise for good behavior; consistent, calm, immediate discipline; choices with 2 options; reinforce limits

  • Talk about what you see; use simple words to describe pictures in books; teach words about feelings; read daily

  • Anticipate anxiety/clingy behavior in new situations

  • No bottle in bed; consistent bedtime & waking up routine
  • Home safety: stair gates; operable window guards if >2nd story room; prevent burns; install smoke detectors

Refer to EMR for vaccines given, CDC handouts given

o Vaccine counseling

o Refusal to vaccinate AAP form signed

o Next routine well-child visit

o Early return OV

o SE (ASQ:SE) screening needed (per AAP)

o ASD assessment/ M-CHAT Follow-up Interview needed

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