Three Year Well-Child Check

Normal Exam Template

  • Parental concerns:

  • General health

    • No new allergies, medications, health issues

    • No parental concerns regarding vision, hearing, oral health

    • Most recent dentist visit:

  • Nutrition: Consumes balanced diet that includes fruits, vegetables, protein, iron rich foods, and < 20 oz 2% milk daily

  • Elimination: Regular voids and no constipation; toilet trained during day

  • Sleep: Regular bedtime; sleeps 10 to 13 hours daily

  • Social history

    • Activities/childcare during day:

    • No parental concerns about behavior, temperament

    • M-CHAT-R/F administered

  • Developmental milestones

    • Uses 2-3 word sentences; speech usually understandable

    • Dresses her/himself and engages in imaginative play

    • Knows that s/he is a girl/boy

    • Draws person with 2 body parts

    • Stands on 1 foot

    • Walks up stairs with alternating feet

  • Anticipatory guidance

    • Screen time < 2 hours daily

    • Always supervised when outside and/or near water

    • Car seat

    • Firearms in household stored unloaded in firearm safe with ammunition stored separately

Assessment and Plan

General Health

  • Acute health issues:

  • Vision/hearing concerns: Refer to ophthalmology/audiology

  • Oral health

    • Encouraged twice yearly dental visits

    • Water source does not contain fluoride: Fluoride drops 0.5 mg/day

  • Nutrition concerns, low iron intake, and/or consuming > 20 oz milk daily: Obtain CBC

  • Toilet training: Parents encouraged to visit https://www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/default.aspx for more information

  • Anticipatory guidance: Counseled about appropriate screen time, water safety, car safety, and gun safety

Vaccination/Universal Screening

  • Vaccination

    • Live attenuated influenza vaccine

      • Pt has received < 2 lifetime doses: Administer first dose now followed by 2nd dose in 4 weeks

      • Pt has received ≥ 2 lifetime doses: Administer 1 dose

    • All other vaccinations up to date

  • M-CHAT-RF

    • 0-2: Normal screen

    • 3-7: Positive M-CHAT-R/F responses reviewed; upon clarification

      • Score < 2: Normal screen

      • Score remains ≥ 2 with provider concern based on observation: Refer to developmental pediatrics

    • 8-20: Refer to developmental pediatrics

  • Not achieving developmental milestones:

    • No previous missed milestones: Reassess in 6 months and refer to early intervention resources and/or medical specialist if issues persist

    • Persistent developmental delay: Refer to early intervention resources and/or medical specialist

Notes

  • Car seat

    • Child may transition to forward-facing car seat when child exceeds weight limit of rear-facing seat

    • Child should remain in forward facing car seat (not booster seat) until age 5 years

  • MCHAT scoring

    • 1 point for YES on items on 2, 5, and 12

    • 1 point for NO on all other items