Transcription of MISSOURI DEPARTMENT OF SOCIAL SERVICES MO …
1 I. INTERVAL HISTORY/PARENT S CONCERNS:History of pregnancy: Gestation _____ weeksComplications:History of delivery: Vaginal C-sectionComplications:Birth Wt: _____ Discharge Wt: _____ Routine NB Care NICUC omplications/Concerns:History:Sleeping:C hild Care:Family High Risk Factors:*Parent s Concerns:Nutrition: Breast _____ min/feeding _____ times per day WIC ReferralNutrition: Formula: _____ , _____ oz/feeding _____ times per dayOutput: Urine: _____ Stools: _____Output:Diaper Rash: _____DATENAMEDATE OF BIRTHMO HEALTHNET NUMBERMEDICAL RECORD NUMBERTEMPRRHEIGHTBMIALLERGIES%NKDAPULSE HEAD CIRCWEIGHTMEDICATIONS%%NONECOMMENTSMISSO URI DEPARTMENT OF SOCIAL SERVICESMO HEALTHNET DIVISIONHEALTHY CHILDREN AND YOUTH SCREENING GUIDENEWBORN (2-3 DAYS) - 1 MONTHMO 886-2727 (11-07)II.
2 UNCLOTHED PHYSICAL EXAM: Check Growth ChartUmbilical Cord _____GeneralSkinHeadEyesEarsNoseOrophary nxNeckLungsHeartPulsesAbdomenAnusBackGUS keletalNeuroSYSTEMNLCOMMENTSABNNESIGNATU REDATEM aternal Substance Use*Immunizations given today:UTD Written information given Consent signed (Follow the recommended immunization schedule approved by the ACIP, AAP, and AAFP)FULL SCREEN (I-X)WITH REFERRALPARTIAL SCREEN (1-V)WITH REFERRALDEVELOPMENTAL & MH SCREENWITH REFERRALHEARING SCREENWITH REFERRALVISION SCREENWITH REFERRALDENTAL SCREENWITH REFERRALIII. ANTICIPATORY GUIDANCE (Check all that apply)IV: LAB/IMMUNIZATIONS: Lab: State newborn metabolic screen drawn Other labs: _____V.
3 LEAD SCREEN N/A for this DEVELOPMENTAL AND MENTAL HEALTH: Parents As Teachers referral(Check all that apply)VII. FINE MOTOR/GROSS MOTOR: (Check all that apply)X. DENTAL: N/Aat this , hiccupsStraining with stoolsParent-child interaction*Father s/Mother s roleFamily planningReading to childDressing/bathingSibling rivalryMinimal SkillsAbility to be soothed*Regards faceResponds to voice/bellCries/makes sound*Minimal SkillsEqual movementsFollows to midlineLifts head while prone-RVIII. HEARING: (Check all that apply)Passed Newborn hearing screenParental perception of hearingAwakes to loud noiseHead turning with noiseEar exam with pneumatic otoscopeObservational screening with noisemakerERA/ABR screen for infant in tertiary care > 5 daysFamily history of hearing disordersPMHx: NICU admission/ ear infection/ head injury/congenital anomalies/ meningitis/ mumps/cerebral palsyIX.
4 VISION: (Check all that apply)Parental perception of visionObservation forblinkingpupillary responsered reflextrackingocular movementFamily history of visual disordersPMHx: NICU admission/ prolonged oxygen administrationNote: Misalignment normal in first six monthsSafe handling of infantSleeping on backCrib safety Co-sleepingWater heater temperature (<130 F)Smoke detectorsCar seatsWhat is a fever?Rectal ThermometerEmerging SkillsSpontaneous smileResponsive smileRegards own handEmerging SkillsFollows past midlineHolds head up 45 degreesPushes chest up while proneCOMMENTSCOMMENTSCOMMENTSCOMMENTSORD ERSSIGNATUREDATES aline nose dropsParental smokingFeeding:Feeding positionIron/VitaminsBreast-feeding supportPacifierColicCOMMENTSMO 886-2727 (11-07)
