ASQ:
Communication:
Gross motor:
Fine Motor:
Problem Solving:
Personal-Social:
Interpretation / Concern / Plan:
Dental assessment performed: No problem suspected, no referral needed
Nutritional Assessment Performed: No problem suspected, no referral needed
Age appropriate anticipatory guidance was reviewed: No problem suspected
Age appropriate developmental assessment was performed: No problem suspected
Age appropriate vision and hearing assessed: No problem suspected
Age appropriate Hgb and Hct assessed: No intervention needed
Lead exposure evaluated: No problem suspected
Urinalysis: No problem suspected or Not indicated
TB risk assessed: No need for intervention
BMI Percentile: _%ile
Smoking:
- Second hand smoke exposure: Yes [_] No [_]
- The patient uses tobacco: Yes [_] No [_]
- The patient/parent was counseled about risks of tobacco use: Yes [_] No [_]
The patient is enrolled in WIC: : Yes [_] No [_]
- If yes, Ht. Wt. and Hgb and Hct checked
Vaccines: Vaccination status was evaluated. Age appropriate vaccines were recommended as follows: as above
Follow Up is recommended in _ months.