WELL CHILD EXAM - INFANCY: 2 MONTHS DATE
(Meets EPSDT Guidelines)
INFANCY: 2 MONTHS
CHILD'S NAME BROUGHT IN BY: DATE OF BIRTH
ALLERGIES CURRENT MEDICATIONS
PARENT TO COMPLETE
ABOUT THE CHILD
ILLNESSES/ACCIDENTS/PROBLEMS/CONCERNS SINCE LAST VISIT TODAY I HAVE A QUESTION ABOUT:
YES NO YES NO
My baby is sleeping well. My baby makes cooing sounds.
My baby is eating, sucking well. My baby lifts his/her head while on tummy.
My baby can see and hear. I do not have frequent times of sadness.
WEIGHT KG./OZ. PERCENTILE HEIGHT CM/IN. PERCENTILE HEAD CIR. PERCENTILE
Diet
Elimination
Review of systems Review of family history
Sleep
Review Immunization Record Other:
Screening: N A Health Education: (Check all discussed/handouts given)
Hearing
Family Planning Safety Sleeping on back
Vision
Development Crib Safety Shaken Baby Syndrome
Development: Circle area of concern
Adaptive/Cognitive Language/Communication Infant Bond Feeding/colic Fever
Gross Motor Social/Emotional
Fine Motor Passive Smoke No bottle in bed Child Care
Behavior Appropriate Car Seat Maternal Depression
Mental Health Other:
Physical: N A N A Assessment/Plan:
General appearance Chest
Skin Lungs
Head/Fontanelle Cardiovascular/Pulses
Eyes/Red Reflex Abdomen
Ears Genitalia
Nose Spine
Oropharynx Extremities/Hips
Neck Neurologic
Nodes
Describe abnormal findings and comments:
IMMUNIZATIONS GIVEN
REFERRALS
HEALTH PROVIDER NAME
NEXT VISIT: 4 MONTHS OF AGE
HEALTH PROVIDER SIGNATURE HEALTH PROVIDER ADDRESS
DSHS 13-683A(X) (REV. 08/2004) - TRANSLATED SEE DICTATION
DISTRIBUTION: White - Physician Yellow - Parent/Guardian
INFANCY: 2 MONTHS
Your Baby's Health at 2 Months
Milestones Health Tips
Ways your baby is developing between 2 "Well child" checkups help keep your baby
and 4 months of age. healthy. Try not to miss these visits. If you do,
call for another appointment.
Lifts head and shoulders up when lying
on his tummy. Keep your baby's immunization history card in a
safe place and bring it to all checkups. If you
Smiles when you speak to her. have questions about immunizations, talk with
Makes sounds like the sounds you make your baby's doctor or nurse.
to him ("aaaaa," "eeeee") Breast milk or formula is all that babies this age
Likes toys that make sounds, like rattles need to grow. Young babies rarely need water.
and squeaks. Avoid giving juice to your baby at this age. When
she is hungry or thirsty, she needs the nutrition in
Holds her own hands and feet. breast milk or formula.
Tries to hold small toys in her hands. You can continue breast feeding when you return
You help your baby learn new skills by to your workplace. For details on breast feeding
playing with her. and working, call Healthy Mothers, Healthy
Babies.
For Help or More Information Sometimes your baby will need to eat more often
than other times. This means she is growing
Child health and development, faster.
immunizations: Healthy Mothers, Healthy Keep your baby away from people who are
Babies Information and Referral Line, smoking. Smoke may cause colds and asthma
1-800-322-2588 (voice) or in babies.
1-800-833-6388 (TTY Relay)
Continue putting your baby to sleep on his back
Breast feeding when returning to the to reduce the chance of Sudden Infant Death
workplace: Healthy Mothers, Healthy Syndrome. Make sure other grandparents and
Babies Information and Referral Line other caregivers put him to sleep on his back
(numbers above) also.
For help if you feel upset with your baby:
Family Help Line, 1-800-932-4673. Parenting Tips
If you have questions about your own When you are with your baby, talk to him, sing to
baby's health: Talk with your baby's him, and look into his eyes. This helps him know
doctor or nurse. you love him. It also helps his brain develop.
Parenting Skills or Support: Family Help Safety Tips
line, 1-800-932-HOPE (4673), Family
Resources Northwest, 1-888-746-9568, Preventing burns:
Local Community College Classes • Check to make sure the bath water is only
lukewarm before bathing your baby.
• Avoid drinking hot coffee, tea, or other drinks
while holding her.
• Keep her out of the sun. Dress her in a hat
with a brim and clothes that cover her arms
DSHS 13-683A(X) (REV. 08/2004)
and legs.
Guidance to Physicians and Nurse Practitioners for Infancy (2 months)
The following highlight EPSDT screens where practitioners often have questions. They
are not comprehensive guidelines.
Hearing Screen
Screen infants with these risk factors:
• Family history of childhood hearing impairment.
• History of congenital prenatal infection with herpes, syphilis, rubella, cytomegalovirus or toxoplasmosis.
• Malformations involving the head or neck (e.g., dysmorphic and syndrome abnormalities, cleft palate, abnormal
pinna).
• Birth weight below 1500 grams.
• Bacterial meningitis.
• Hyperbilirubinemia requiring exchange transfusion.
• Severe prenatal asphyxia exchange transfusion.
• Severe prenatal asphyxia (Apgar scores of 0-3, absence of spontaneous respirations for 10 minutes or hypotonia
at 2 hours of age).
• Parents concerned about infant's hearing.
Developmental Milestones
Always ask about and follow-up on parent concerns about development or behavior. You may use the
following screening list, or the Denver II, or the ELMS2 (a language screen).
Yes No
Vocalizes.
Smiles responsively.
Follows to mid line.
Responds to sounds.
Instructions for developmental milestones: At least 90% of infants should achieve the underlined
milestones by this age. If you have checked "no" on any two items or on even one of the underlined
items, refer the infant for a formal developmental assessment.
Notes: Immunization schedules are from the Advisory Committee on Immunization Practice of the U.S. Centers for Disease
Control and Prevention. Parents and providers may call Healthy Mothers, Healthy Babies (1-800-322-2588) with questions
or concerns on childhood development.
DSHS 13-683A(X) (REV. 08/2004)
