Well-Child Visit: 1st Week
Age:_______days
CG’s Name:
History 
 Mom
 Dad
 Sibling(s)
Who is at the WCV?
Grandparent
 Foster parent
 Other Caregiver
Health or feeding concerns?
EPSDT
 Hx/Nutr/Devel
 Unclothed PE
 Labs
 Health Educ
 Vision Screen
 Hearing Screen
 Immunizations
 Dental Referral
PE 
Vitals & Growth Parameters
T
C/F ax/rect/tymp P
HC
_ cm (
Wt
__________________________________________________
Nutrition / Activity 
 Breastfeeding q
________
Position/ Latch & Suck?
Nipple soreness?
hrs,
__
 Appropriate
 Yes
min/side
 Problematic
 No
__________________________________________________
Breast pumping?_____________X qd (~10 min after every
feeding, q 2 hrs or 8-10X daily?)
 Formula =
oz q
____
hrs or
oz/day
Elimination: BMs:______________ Voids:_______________
Past Medical History (Dev-Behav. Risk Factors) 
 Prenatal, delivery & neonatal history reviewed; see EMR
(+) findings:________________________________________
© Kevin Marks MD, 2012; Last Revised 2-22-2012
R
_%) Length
kg (birth wt
BP
cm (
_ _ kg) wt / ht ratio
/
%)
%
GEN
HEENT
Chest/Lungs
CV/Heart
ABD
GU
Skin
MSK/Spine
Neuromotor
Parent-Child Interaction
Other:
Assessment
Growth:  Term
 AGA
 Breastfed
 Feeding nl
 _________ weeks preterm
 LBW, SGA or IUGR  LGA
 Formula fed
 Both
 Feeding problems
<10% BW
Development & Behavior:
 Typical
 “At-risk”
 Automatically EI-eligible
Icterus & Other:  Typical  Jaundice  EMR problem list
updated
Plan
Gest. Age________________wks
Preterm?  Yes  No
 LBW
 SGA
 IUGR
 LGA
 IDM
 In Utero Exposure to:_______________________________
Administered:  AAP Pediatric Intake Form/ Family
(per AAP)
Psychosocial Screen (FPS) or
 Parent Screening Questionnaire (PSQ)
Meds, Allergies
Family Hx
Updated in EMR
see FPS or PSQ________________________
__________________________________________________
Social Hx
see FPS or PSQ
Newborn well baby handout (Bright Futures: Infancy)
 AAP SIDS Prevention handout
 Vitamin D 400 IU PO qd (with iron if premature)
 Electric breast pump
 Lactation referral_________________________________
Guidance 

___

__________________________________________________
Tobacco exposure?  Yes  No
DV?  Yes  No
Medical Screening 
1st newborn screen:  Normal  Results pending
PE: Sensory Screening 
Red Reflex:
 Present bilaterally
Corneal light reflex:  Symmetrical
Hearing behavior:  Startles
 Calms to voice
Newborn OAE or ALGO  Passed  Refer on R &/or L side(s)



Breastfeeding promotion; AAP recommended goal is 12
months or longer but exclusive breastfeeding for the first
4-6 months is ideal; wait 4-6 weeks to introduce pacifier
SIDS prevention: back to sleep position; firm mattress; no
soft bedding, no pillows; sleep in same room as baby;
smoke-free environment; crib w/ slats <2 3/8 inches apart
Family readiness: community resources can help!
Create nurturing routines; physical contact (holding,
carrying and rocking) makes baby feel secure
Smoke free home & vehicle; avoid others with cold & flu
Immunizations 
 Hepatitis B vaccine given after birth; EMR updated
Follow up / Return
 Next routine well-child visit
 Early return OV