1. www.littleseedpediatrics.com
PREVENTATIVE WELL CHILD VISIT 7 to 10 years
Patient Name__________________________________________________ D.O.B.___________________ Date_________________________
Gender □ M □ F Age ________ yr. _________mo. Accompanied by ______________________________ Initials ____________
□ NKDA Known Drug Allergies _________________________________ Medications ________________________________________ □ NONE
HISTORY/DEVELOPMENT
Special health needs ___________
_____________________________
Dental visits _______ times/year
Food allergy __________________
Sleep [hrs/night] _____________
Physical activity [min/day] ____
_____________________________
Screen time [hrs/day] _________
SCHOOL/BEHAVIOR
Grade Level ______________________
Performance □ A-B □ C □ D-F
Extracurricular activity _____________
__________________________________
Social relationships ______________
__________________________________
Behavior/self esteem ______________
__________________________________
NUTRITION – Servings/day
Milk/Dairy _____________/day
Fruits/Vegetables _______/day
Meat/Beans/Eggs _______/day
Carbohydrates __________/day
Sweets/Drinks/Junk ____/day
Vitamins/Supplements _______
____________________________
Special diet __________________
SOCIAL/FAMILY HISTORY
After school care plans
___________________________
Smoker[s] in home □ Yes □ No
Changes in household since last
visit ___________________
___________________________
___________________________
Vitals: Weight _________lbs_______% Height _______in_______ % BMI ______/_______ %
B/P _______/_______ HR (pulse) _______ Temperature _______
ASSESSMENT/PLAN
□ Well □ Other See back
Counseled/VIS Given
□ Flu □ Flumist
.
Prev. counseling _______ minutes
___________________________
RTC _______________________
PROVIDER’S SIGNATURE ______________________________________________________
Anticipatory Guidance
□ Discussed/handout given
School
Show interest in school
Quiet space for homework
Address bullying
Mental Health
Encourage independence
and self-responsibility
Praise strengths
Be a positive role model-
discuss anger, respect
Know child’s friends and
importance of peers
Expect preadolescent
behaviors
Answer questions and
discuss puberty
Safety rules with adults
Nutrition & Physical Activity
Encourage proper nutrition
Eat meals as a family
60 minutes exercise/day
Limit TV/screen time
Oral Health
Dentist visits 2x/yr
Brushing 2x/day
Floss daily
Wear mouth guard during
sports
Safety
Know child’s friends
Home emergency plan
Safety rules with adults
Appropriate vehicle
Helmets and pad
Supervise around water
Smoke-free environment
Guns
Monitor computer use
Sun protection
Physical Exam N DESCRIPTION OF FINDINGS
APPEARANCE
SKIN
HEAD
E.E.N.T. □ Contacts □ Glasses
NECK
NODES
LUNGS
HEART
BREAST/CHEST Tanner Stage
ABD
PULSE
G/U Tanner Stage
BACK
EXTREMITIES
NEURO
![www.littleseedpediatrics.com
PREVENTATIVE WELL CHILD VISIT 7 to 10 years
Patient Name__________________________________________________ D.O.B.___________________ Date_________________________
Gender □ M □ F Age ________ yr. _________mo. Accompanied by ______________________________ Initials ____________
□ NKDA Known Drug Allergies _________________________________ Medications ________________________________________ □ NONE
HISTORY/DEVELOPMENT
Special health needs ___________
_____________________________
Dental visits _______ times/year
Food allergy __________________
Sleep [hrs/night] _____________
Physical activity [min/day] ____
_____________________________
Screen time [hrs/day] _________
SCHOOL/BEHAVIOR
Grade Level ______________________
Performance □ A-B □ C □ D-F
Extracurricular activity _____________
__________________________________
Social relationships ______________
__________________________________
Behavior/self esteem ______________
__________________________________
NUTRITION – Servings/day
Milk/Dairy _____________/day
Fruits/Vegetables _______/day
Meat/Beans/Eggs _______/day
Carbohydrates __________/day
Sweets/Drinks/Junk ____/day
Vitamins/Supplements _______
____________________________
Special diet __________________
SOCIAL/FAMILY HISTORY
After school care plans
___________________________
Smoker[s] in home □ Yes □ No
Changes in household since last
visit ___________________
___________________________
___________________________
Vitals: Weight _________lbs_______% Height _______in_______ % BMI ______/_______ %
B/P _______/_______ HR (pulse) _______ Temperature _______
ASSESSMENT/PLAN
□ Well □ Other See back
Counseled/VIS Given
□ Flu □ Flumist
.
Prev. counseling _______ minutes
___________________________
RTC _______________________
PROVIDER’S SIGNATURE ______________________________________________________
Anticipatory Guidance
□ Discussed/handout given
School
Show interest in school
Quiet space for homework
Address bullying
Mental Health
Encourage independence
and self-responsibility
Praise strengths
Be a positive role model-
discuss anger, respect
Know child’s friends and
importance of peers
Expect preadolescent
behaviors
Answer questions and
discuss puberty
Safety rules with adults
Nutrition & Physical Activity
Encourage proper nutrition
Eat meals as a family
60 minutes exercise/day
Limit TV/screen time
Oral Health
Dentist visits 2x/yr
Brushing 2x/day
Floss daily
Wear mouth guard during
sports
Safety
Know child’s friends
Home emergency plan
Safety rules with adults
Appropriate vehicle
Helmets and pad
Supervise around water
Smoke-free environment
Guns
Monitor computer use
Sun protection
Physical Exam N DESCRIPTION OF FINDINGS
APPEARANCE
SKIN
HEAD
E.E.N.T. □ Contacts □ Glasses
NECK
NODES
LUNGS
HEART
BREAST/CHEST Tanner Stage
ABD
PULSE
G/U Tanner Stage
BACK
EXTREMITIES
NEURO](https://image.slidesharecdn.com/19c548cc-55bb-484c-af5c-fc7eb60fe331-150406174741-conversion-gate01/85/PREV-HEALTH-VISIT-7-to-10-yrs-1-320.jpg)
