brevaWell-child visit
Encounter
Patient name: [ ] Date of birth: [ ] Date and time of encounter: [ ] Clinician: [ ]
History
Parent, caregiver or patient present: [ ] Concerns raised: [ ] Interval history since last visit: [ ] Feeding or nutrition, sleep, elimination and activity as reported: [ ] School or childcare and behavior as reported: [ ]
Growth and vitals
Weight, length or height and head circumference if measured, with units and percentiles: [ ] Body mass index percentile if calculated: [ ] Other vitals measured, with units: [ ]
Development and screening
Developmental or behavioral screening tool and result: [ ] Other screening performed and results: [ ] Vision and hearing screening and results if performed: [ ]
Examination
Examination performed and findings: [ ]
Immunizations
Immunization record reviewed: [ ] Vaccines given today, with product, lot, site and route: [ ] Vaccines deferred or declined and reason: [ ]
Assessment and plan
Problems addressed today: [ ] Anticipatory guidance discussed: [ ] Referrals and orders: [ ]
Follow-up
Follow-up timing and purpose: [ ] Return precautions discussed: [ ] Patient questions and understanding: [ ]