Form F-01058f "General Pediatric Clinic/12 Month Visit" - Wisconsin

What Is Form F-01058f?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the Wisconsin Department of Health Services;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-01058f by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-01058f "General Pediatric Clinic/12 Month Visit" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068F (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 12 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 12 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Activity
Exploration
Feeding: Milk, type ______________ Amt / day _____________ oz.
Adaptability to Examiner
Breast _____ Bottle _____ Cup _____ Fingers _____
Spoon _____ Solids and Meals / day
Distractibility
Sleeping: Night
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Nap
Behavior
Part
N
Abn
Skin: Color, texture, hair, scalp
Review of Family — Social and Health
Head and Face: Symmetry, AF Size _____ cms_____
Eyes: Pupils, conjunctivae, EOM, red reflex
Ears and Nose: Canals, tympanic membranes, turbinates
Nose: Discharge
Parents’ Description of Baby’s Temperament
Mouth: Gums, tongue, # of teeth
Nodes: Cervical, inguinal
Lungs:
Heart: Rhythm, S1, S2, murmur
Problems Identified and Reviewed
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Extremities: Range of motion, stance
Neuromuscular: Tone, strength, equilibrium, coordination,
Physical and Emotional Status
Gate, DTRs
Diet: Weaning, drop in appetite, table foods.
Describe abnormal findings.
Add citrus fruits
R = Reported
O = Observed
Development Observation
Anticipatory Guidance: Negativism, manipulative behavior, setting
R
O
NO*
NO* = Not observed by parents or examiner
limits, consistency in approach, expectations on toilet training.
G.M.
Stands holding on to furniture
Speech stimulation. Review of fever control and care of minor
Walks holding on to furniture
illnesses.
Stands alone briefly
Safety: Pot handles, stairs, gates, plants, PICA, Car seat, temperature
Stands alone well
taking, lead exposure.
Walks
alone
Stoops and recovers without holding on
Bangs cubes held in two hands
Immunizations
Drug Co. and Lot No.
Expiration Date
Pincer grasp
Scribbles spontaneously
Lang.
Vocalizes and communicates without words
Mama and Dada — nonspecific
Mama and Dada — specific
 Blood lead test done
More than two single words
 Other Lab tests _________________________________________
P.S.
Plays repetitive games
SIGNATURE — Provider
Date Signed
Plays ball with examiner
Feeds self using fingers
Drinks from cup with help
Comforted by parents' voices
Return to clinic in _____ months.
Quiets at parent's touch
Needs cuddling for reassurance
O = Observed
M = Mother
F= Father
NO* = Not observed here
Parents’ Interactions with Baby
O NO
*
O NO
*
Talks to the baby
Limits activity by physical actions
Responds only when baby cries
Limits activity by verbal command
Allows baby to explore
Voice calm while talking to baby
Sits back during exam
Reinforces behaviors through approval and attention
Watches baby during visit
Other Observations
Development and Parent-Child Interaction
Reset Form
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068F (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 12 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 12 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Activity
Exploration
Feeding: Milk, type ______________ Amt / day _____________ oz.
Adaptability to Examiner
Breast _____ Bottle _____ Cup _____ Fingers _____
Spoon _____ Solids and Meals / day
Distractibility
Sleeping: Night
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Nap
Behavior
Part
N
Abn
Skin: Color, texture, hair, scalp
Review of Family — Social and Health
Head and Face: Symmetry, AF Size _____ cms_____
Eyes: Pupils, conjunctivae, EOM, red reflex
Ears and Nose: Canals, tympanic membranes, turbinates
Nose: Discharge
Parents’ Description of Baby’s Temperament
Mouth: Gums, tongue, # of teeth
Nodes: Cervical, inguinal
Lungs:
Heart: Rhythm, S1, S2, murmur
Problems Identified and Reviewed
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Extremities: Range of motion, stance
Neuromuscular: Tone, strength, equilibrium, coordination,
Physical and Emotional Status
Gate, DTRs
Diet: Weaning, drop in appetite, table foods.
Describe abnormal findings.
Add citrus fruits
R = Reported
O = Observed
Development Observation
Anticipatory Guidance: Negativism, manipulative behavior, setting
R
O
NO*
NO* = Not observed by parents or examiner
limits, consistency in approach, expectations on toilet training.
G.M.
Stands holding on to furniture
Speech stimulation. Review of fever control and care of minor
Walks holding on to furniture
illnesses.
Stands alone briefly
Safety: Pot handles, stairs, gates, plants, PICA, Car seat, temperature
Stands alone well
taking, lead exposure.
Walks
alone
Stoops and recovers without holding on
Bangs cubes held in two hands
Immunizations
Drug Co. and Lot No.
Expiration Date
Pincer grasp
Scribbles spontaneously
Lang.
Vocalizes and communicates without words
Mama and Dada — nonspecific
Mama and Dada — specific
 Blood lead test done
More than two single words
 Other Lab tests _________________________________________
P.S.
Plays repetitive games
SIGNATURE — Provider
Date Signed
Plays ball with examiner
Feeds self using fingers
Drinks from cup with help
Comforted by parents' voices
Return to clinic in _____ months.
Quiets at parent's touch
Needs cuddling for reassurance
O = Observed
M = Mother
F= Father
NO* = Not observed here
Parents’ Interactions with Baby
O NO
*
O NO
*
Talks to the baby
Limits activity by physical actions
Responds only when baby cries
Limits activity by verbal command
Allows baby to explore
Voice calm while talking to baby
Sits back during exam
Reinforces behaviors through approval and attention
Watches baby during visit
Other Observations
Development and Parent-Child Interaction
Reset Form
GENERAL PEDIATRIC CLINIC / 12 MONTH VISIT
ANTICIPATORY GUIDANCE FOR 12 MONTH VISIT
F-01068F (01/11)
Page 2
Diet
Speech Stimulation
Weaning — Breast-feeding weaning actually may have started a
Around one year, children make all kinds of sounds. Speech consists
few months back as the baby may have cut back to three nursings.
of words put together with certain intonations. Language includes
The mother can gradually decrease the number of feedings, often
speech or expressive language and understanding through hearing or
leaving the night feeding to last. Some children will be so
bodily motions, which is receptive language. Receptive language has
interested in the environment that they don't nurse completely and
been developing since birth. Most parents will say "they understand
the milk will decrease so the whole process is spontaneous and
everything I say," and through body language the child is able to
painless. If the mother wants to stop all of a sudden, she will feel
express themselves so that the parents also understand. Speech has
discomfort for a few days.
to be taught. It is done by mimicking the parents. Adult speech is long
and complicated. For the child to mimic the sentence structure, it
Table foods can be encouraged totally with cup, spoon, and fingers
should be grammatically correct with the proper intonations but
used for self-feeding. The appetite may drop automatically in some
shortened and the word labeling the object being discussed,
children. If allowed to feed themselves, and offered a good
repeated. This is called labeling. For example, "Here is a glass of
balanced diet, the children will lose their baby fat and maintain a
milk" (as the parent gives the milk to the child) and then repeat "milk."
more proportional weight to the height. Parents need a lot of
reassurance at this time that the child will not starve. The poor
Safety
weight gain is normal and the new body dimensions are healthy.
Car seats need to be reinforced even though the child may raise
Many parents will feed, give frequent snacks, and use food for
objections, especially if not consistently placed in the car seat. Pot
reward or bribe for the child's other demands. This can set up an
handles should be turned in as they present temptation to reaching
eating problem such as obesity, poor diet, or control of parents with
hands. Plants must be placed out of reach. Stair gates are used
food.
until the child can be consistent at sliding down or climbing up.
Sometimes, giving the parents the permission to use one vitamin
PICA — the eating of non-edibles needs to be watched.
per day will relieve their anxiety regarding health needs and, with
Swallowed or aspirated objects can cause major medical
a lot of reinforcement, they will let the child develop good eating
problems in this second year of life.
habits. They should be told to call the vitamin a vitamin and not
candy and warned that the child can be poisoned from too many
Lead Exposure
vitamins.
Sources include: Lead-based paint, gasoline, solder. Possible
pathways include: air, drinking water, food. Lead-based paint is the
Anticipatory Guidance
most common high dose source of lead in children. About 74 percent
Manipulative behavior — a 1-year old can manipulate his or her
of privately owned, occupied housing units in the U.S. built before
parents with his or her eating or lack of it. They also can use
1980 contain lead-based paint (CDC, October 1991).
crying, smiling, or looking cute to manipulate parents. The parents
have to realize that this behavior often exists. Negativism is usually
Review fever control and care of minor illnesses, adjust antipyretic
not severe but if everything he touches is a "no-no," the child may
doses, and warn about overdoing. The child needs to be told these
mirror the behavior. Setting limits and consistency in approach is
are medicine and not candy.
extremely important and useful for the child in learning discipline.
Inconsistency confuses the child and no limits make them
insecure. A pattern can be started at this age and carried through
the toddler years so that the child can know his or her limits and be
disciplined in later years when parental influencing is in conflict
with peer pressure.
Toilet Training
Find out the degree of interest felt by the parents. Discuss the
norms in the United States and the physiologic development of the
child. If the parents are not interested, then postpone what follows
until the next visit. If they want to start toilet training, the child needs
to be able to sit and get up when they want to or stand and move
away from the toilet freely. They need to know the bladder and
bowel signals. They need to dislike the feeling of urine or stool in
the diaper and also want to please the parents in putting all these
skills together to get to the toilet in time to perform. Children vary in
development of all of these above skills. Girls seem to dislike the
soiled diapers more than the boys do. She shows this by coming to
the parent and wanting the diapers changed as soon as soiled. A
child often shows recognition of bladder and bowel control function
by stopping play or other activities for awhile.
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