4-5 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

  • Elimination: Regular voids and no constipation; toilet training complete

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

  • Activity: Plays for ≥ 60 minutes daily

  • Social history

    • School (plans):

    • No parent or teacher concerns about behavior, temperament, attention, performance

  • Developmental milestones

    • 4 Year: Speech usually understandable, engages in fantasy play with peers, knows name/age/gender, names 4 colors, dresses self and brushes own teeth, draws person with 3 body parts, hops on 1 foot

    • 5 Year: Good articulation/language skills, counts to 10, names 4 colors, copies squares/triangles, prints some letters, draws person with 6 body parts, hops on 1 foot

  • Anticipatory guidance

    • Screen time < 2 hours daily

    • Always supervised when outside and/or near water

    • Always wears helmet

    • Car seat

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

Assessment and Plan

  • 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

  • Educated about appropriate nutrition and physical activity

  • Concerns about attention/school performance: Consider administering Vanderbilt Assessment Scales for ADHD in cases of severe dysfunction

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

  • Vaccinations

    • Administer 4th Polio, 5th DTaP, 2nd MMR, and 2nd varicella if not yet completed

    • 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

  • Not achieving developmental milestones

    • Has not started school: Refer to early intervention resources and/or medical specialist

    • Notify school about concerns

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

  • ADHD can be diagnosed and treated as young as four years, but there is little evidence to support this practice