Name_____________
Date______________
4 month
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Concerns about maternal depression ____yes ____no
Reactions of sibling to new child _________________________________________
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
Development
Social Emotional: ___Smiles ___Looks at parents ___Self-comfort
Communication: ___ Coos ___ Different cries for different needs
Cognitive: ___ Indicates boredom when no activity change
Physical: ___ Lifts head and begins to push up when prone
___ Holds head erect for short periods (when held up right)
___ Diminished newborn reflexes
___ Symmentrical movement
Additional comments: ____________________________________________________________
________________________________________________________________________________
