Name_____________

Date______________

4 Month

Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Concerns about maternal depression ____yes ____no
Parents working outside home ____mother ____father
Child Care ____yes ____no Type______________________________________
Changes since last visit _________________________________________________
Diet
Milk ____________________________________
Type ____________________________________
Amt/Time per feeding ____________________________________
Frequency _______________________________________________
Source of water ______________ Vitamin D ____yes ____no
Bowel/Bladder
Stool Concerns ____yes ____no
Stool Consistency ____hard ____soft
Urination Concerns ____yes ____no
Sleep
Back sleeping ____yes ____no
Location ____co-sleep ____crib ____co-sleep & crib
Duration ____ < 3 hrs ____ 3-6 hrs ____ > 6 hrs
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Activity (tummy time, no TV) ____________________________________________________
Development
Social Emotional: ___ Social Smile ___Elicits social interactions
___ Can calm down on own
Communication: ___ Spontaneous expressive babbling
Cognitive: ___ Responds to affection ___ Indicates pleasure and displeasure
Physical: ___Pushes chest up to elbows ___Good head control
___Symmetry in movements
Additional comments: ____________________________________________________________

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