Well-Visit Encounter Forms*
In Chapter 5 we provide a flow chart for efficient deployment of the American Academy of Pediatrics’ policies on detecting and addressing developmental-behavioral problems in primary care. The flow chart staggers the various tasks in order to ensure manageable lengths for each well visit. Also included is a longitudinal problem/process checklist useful for tracking screening and surveillance activities over time.
More immediately, we want an indicator at each well-visit about needs doing and what has been done. Quality age-by-age encounter forms are enormously helpful for ensuring the tasks of screening/surveillance are accomplished and that requisite health issues are addressed.
On this webpage we provide:
- Downloadable age-specific encounter forms (in Word). These forms are modifiable so that you can insert regional issues (e.g., snake bite prevention in southern US States versus frost-bite prevention in northern US States). The list below includes the age-ranges with links to the various well-visit forms:
- An introduction to the many abbreviations for health and developmental-behavioral tasks is described below.
Caveats and Admonitions
Note that these forms do not provide a list of milestones. Unlike accurate screens, evidence for informal checklists shows they do not detect most children with deficits [e.g., those provided in the AAP/Bright Futures (3rd edition pocket guide/toolkit), Reach Out and Read’s checklist, the CDC’s Act Early questionnaire, etc.)] 1-3 Informal items are usually rooted in the 50th percentile meaning half of all patients will not do well—essentially giving you nothing to go on. Thus you will flounder for what to do with results, meaning most likely, under-refer. You are encouraged to remove milestones checklists on your own well-child encounter forms and replace them with the results of viable screening tests as shown in the various age-specific encounter forms (and described further in Chapter 16 Implementation). The same issue applies to eliciting parents’ concerns. Informal questions to parents are fine as conversation starters (e.g., “What have you been doing since I saw you last?” but are not thorough probes for the issues families want to discuss (and for making decisions based on parents’ concerns). Evidence-based questions are essential.
Directions, Mnemonics/Abbreviations and Definitions
The WCV templates are meant to be used with the content of Chapter 5 (screening and surveillance for children 0 to 6 years of age) and with Chapter 9 (screening and surveillance with children 6 years and older). Illustrated are the tasks required and the age at which they are required.
Each WCV templates has two columns on the first page. At the top left are identifiers with these abbreviations:
|Age_mo||age in months|
|CG's name||Caregiver's name|
Within the two columns are 15 headers. We list these headers below, in order of appearance, along with a description of needed input by providers, and definitions for the many abbreviations and mnemonics—either listed on the forms or commonly inserted by providers.
In addition, the 8 specific tasks required for an Early Periodic Screening Diagnosis and Treatment (EPSDT) visit (listed and numbered at the top of the WCV forms) are explained below.
A few common abbreviations used throughout the forms (or used by providers to document findings) include:
|HPI||History of the Present Illness|
|qid||4 Times a Day|
|BID or 2x qd||Twice a Day|
|TID||Three Times a Day|
|PO||Per OS (by mouth)|
|Kg||Kilograms (clinicians usually describe a child’s weight in kilograms. If you need to convert these to pounds (lbs) this website is helpful: Metric Conversion|
|SIDS||Sudden Infant Death Syndrome|
Patient History (EPSDT task #1)
Includes space to list prior health/growth concerns as well as ongoing issues. Medical problems such as congenital hypothyroidism, PKU, iron deficiency anemia, or lead poisoning negatively affect a child’s developmental-behavioral trajectory (i.e., are serious biological or environmental risk factors).
Interval Hx (Hx = History) is space to comment on prior visits and parents’ answers to such questions as: Since the child's last well visit, what has (or has not) happened? Any illnesses, office visits or trips to the emergency room? Any sub-specialty consultation visits or interventions? Any missed well visits? Any missed appointments for previously recommended follow-up or consultation appointments?
Nutrition/Activity (EPSDT Task #1)
This section includes a number of prompts regarding what a child eats. There is space in this section to comment on physical activity. Providers sometimes write:
5-2-1-0" = 5 servings of vegetables & fruits per day, 2 hrs or less of screen time per day, 1 hr of physical activity per day, 0 sweetened drinks & 0 trans fats per day
5-4-3-2-1-0 Go!"... which is mostly the same as above but includes 4 cups of water & 3 cups of lowfat milk per day. It is usually more helpful to tell parents and kids what to eat, rather than always rambling on about what not to eat. Other abbreviations are:
|MTV w/ iron||multivitamin with iron|
Development/Behavior/Learning (EPSDT Task #1) and Abbreviations for Screening Tools
Under Dev./Behav./Learning is space to identify which screening measures were administered and the results. Abbreviations for commonly used measures are listed here:
|ASQ||Ages & Stages Questionnaire|
|ASQ:SE||Ages & Stages Questionnaire: Social-Emotional|
|ASD||Autism Spectrum Disorder|
|*CRAFFT||Screen= Car, Relax, Alone, Forget, Family or Friends, Trouble|
|*ESP||Eating disorder Screen of Primary Care|
|IEP||Individualized Educational Plan|
|M-CHAT||Modified Checklist of Autism in Toddlers|
|PEDS||Parents' Evaluation of Developmental Status|
|PSC||Pediatric Symptom Checklist|
|Pictorial PSC||Pictorial Pediatric Symptom Checklist (shown in full in Chapter 9)|
|Y-PSC||Youth report Pediatric Symptom Checklist|
|*HEEADSSS||Home, Education (and/or Employment), Eating, Activities, Drugs, Safety, Sex, Suicidality/mental health|
Dental (EPSDT Task #8)
This section reminds practitioners to ask about oral health issues and help prevent them. Boxes should be checked when prevention-based procedures are accomplished (e.g., tooth brushing twice a day, fluoride varnish, dental appointments, etc.)
The acronym “BEARS” is the most efficient way to document sleep issues. BEARS stands for:
|Bedtime Problems:||Does your child have any problems going to bed? Falling asleep?|
|Excessive daytime sleepiness:||Does your child seem overtired or sleepy a lot during the day? Does she still take naps?|
|Awakenings during the night:||Does your child wake up a lot at night?|
|Regularity and duration of sleep:||Does your child have a regular bedtime and wake time? What are they?|
|Snoring:||Does your child snore a lot or have difficulty breathing at night?|
Past Medical History, Medication, and Allergies (PMH)
Past Medical History, medications, and allergies should be updated in the problem checklist which is typically housed in the front of the patient chart. Certain medical conditions (e.g., obstructive sleep apnea) and medications (e.g., anti-seizure meds) can increase the risk of a developmental delay or other future developmental-behavioral problem. At every visit, update your problem and medication lists. The large majority of clinics are now using EMR systems to track pertinent medical conditions and all medications. Many practices have a process where a qualified nurse is responsible for updating the EMR medication list for you. In other practices, pediatric providers feel strongly about updating the medication list themselves.
|IDM||Infant of a Diabetic Mother|
|IUGR||In-Utero Growth Retardation|
|LGA||Large for Gestational Age|
|LBW||Low Birth Weight|
|SGA||Small for Gestational Age|
Abbreviations for Tools To Gather Family and/or Social History
|*FPS||Family Psychosocial Screen|
|*BPCIS||Brigance Parent Child Interaction Scale|
|PSQ||Parent Screening Questionnaire|
Family History (Family Hx)
At the time of new patient intake (which is often at birth) consider use of an evidence-based tool such as the FPS (shown in full in Chapter 10 and downloadable at www.pedstest.com/TheBook/Chapter10). The FPS probes for a wide range of psychosocial risk factors including depression, substance abuse, parent education, employment status, social support, parents’ history of abuse as a child, guns in the home, domestic violence, etc. The FPS also includes questions about family medical status (e.g., “high blood pressure”, “lung problems/asthma”, “nerve problems”, “diabetes”, “heart problems”, and “smoking in the home) but additional questions are needed to probe for history of speech-language deficits, autism, hearing loss, vision problems, and genetic disorders.
Social History (Social Hx)
The space for social history is used to update significant family issues found at new patient intake, along with response to recommended interventions [e.g., tobacco exposure, domestic violence (which is noted as DV on the templates)]. The AAP also recommends rescreening for post-partum depression in the 1st and 2nd year of life. For this task, selected items from the FPS or PSQ are brief and useful. Included on the back of the WCV for the 1 month and 12 month visits are the 3 FPS items for depression screening along with scoring directions.
Even at the earliest well-visits, we should encourage parents to promote development by talking with their baby, sharing books, taking him/her places and teaching new things, etc. At 6 months and again at 15 months, we need to affirm that our advice is working. The BPCIS is helpful for capturing (either by parent-report or by examiner observation) critical resilience/protective factors (e.g., whether parents are providing an enriched language environment, enjoy child-rearing, etc.). The BPCIS is shown in full in Chapter 10 and downloadable at www.pedstest.com/TheBook/Chapter10 in both its parent report and examiner observation versions (in English and Spanish). The 8 critical observation items are shown on the back of the downloadable 6 and 15 month WCVs along with scoring and referral recommendations.
Medical screening (EPSDT Task #3)
This section is used to capture results of any medical screens administered. Certain medical screening recommendations (e.g., lead screening) often vary based on the population served but, in general, the friendly reminders within these WCV forms diligently follow the AAP/Bright Futures recommendations and the advice of up-to-date, peer-reviewed research articles. Whenever a child is identified with a suspected developmental-behavioral disorder, consider an early return office visit to reassess the child more thoroughly. Part of this assessment may include laboratory tests to screen for an iron deficiency anemia, elevated blood lead level, genetic or metabolic disorder, etc.
To detect iron deficiencies, hemoglobin (Hgb) screening should always be used in combination with a focused dietary history. If the dietary history is highly suggestive of an iron deficiency, some experts recommend a complete blood count (CBC), ferritin and CRP (to make sure that the ferritin is not falsely elevated). Other tests, such as reticulocyte hemoglobin content, may someday prove to be more reliable measures of an iron deficiency. If your physical exam confidently detects a neuromotor delay, then a creatinine kinase (CK) and thyroid stimulating hormone (TSH) should be considered for children with low or normal muscle tone and a brain Magnetic Resonance Imaging (MRI) should be considered for children with increased tone/spasticity. But for the other, more routine medical screening recommendations, please refer to Bright Futures.1 Abbreviations on the WCV forms are as follows:
|CBC||Complete Blood Count|
|OGTT||Oral Glucose Tolerance Test|
|TST||TB Skin Test|
Physical Exam(PE) Sensory Screening (EPSDT Tasks 5 & 6)
Vision and hearing screening recommendations are presented on these WCV forms in a planned and periodic manner as recommended by the AAP/ Bright Futures and EPSDT guidelines. Based on the recommendations of AAP policy statements, peer-reviewed articles and national experts, specific methods or tools have been suggested to enhance your ability to identify (and refer) children with vision and hearing problems. Whenever a child is identified with a suspected developmental-behavioral disorder, you should also consider a vision or hearing screening as part of that child’s assessment at an early return office visit. There is space to check off problems with cover tests, corneal light reflex, response to sounds.
|ALGO||brand name device for newborn hearing screening|
Physical Exam (PE) (EPSDT Task #2)
It is crucial to remember that the large majority of children with developmental-behavioral problems will not have any overt dysmorphology. To identify medical conditions that contribute to developmental-behavioral problems, the results of your developmental-behavioral and family psychosocial screens are essential. Your unclothed (per EPSDT guidelines) physical examination should include attention to the child’s growth parameters (including head circumference and shape), facial and other body dysmorphology, eye ﬁndings (e.g., cataracts in various inborn errors of metabolism), vascular markings, and other signs of neurocutaneous disorders (e.g., café-au-lait spots in neuroﬁbromatosis, hypopigmented macules in tuberous sclerosis), muscle strength, tone, presence of abnormal reﬂexes, and disturbance of movement.
Blood pressure screening is an important part of the AAP/Bright Futures health supervision guidelines. Unfortunately, physicians and nurses frequently under-identify children with an elevated blood pressure in their well visit notes. The blood pressure cut-offs provided in the vitals section of these WCV forms represent the lower limits for abnormal blood pressure ranges, according to age and gender. Any blood pressure reading equal to or greater than these values represent blood pressures in the prehypertensive, stage 1 hypertensive, or stage 2 hypertensive range and should be further evaluated by a physician. Blood pressure should also be diligently monitored whenever children are prescribed medication for Attention Deficit Hyperactivity Disorder (ADHD) and other psychiatric conditions.
The term, “Parent-child interactions” is bolded in order to remind practitioners to routinely observe and document parent-child interactions. Although this may have been accomplished with the BPCIS, when doing a physical exam on a child who has a history of being abused and/or neglected, parent-child interactions should alert you that something is seriously wrong with the family dynamics. “Other” is space to note additional findings. Abbreviations include:
|BMI||body mass index|
|T (C)||temperature (Celcius)|
|HEENT||head, ears, eyes, nose & neck, throat|
|SMR||sexual maturity rating|
|Neuro||(see Chapter 5 for details)|
This section summarizes findings including history of growth, weight gain (or lack thereof) in light of developmental/behavioral problems uncovered. Thou cannot treat what thou cannot identify! These WCV forms intentionally guide practitioners away from routinely labeling children with the overly used terms, “well child” or “normal growth and development”. Also commonly used is “WNL”, meaning “Within normal limits”, a term that often stands for “Would Not Look”! Many a child is not a “well child” (i.e., free of any health, developmental or behavioral conditions). Falsely reassuring labels along with a plan to just “wait and see” are ill-advised. Treating promptly is the most beneficial approach.
Developmental delays, family psychosocial risk factors and other conditions such as hypertension are commonly under-identified in WCV notes too. By encouraging periodic screening, these WCV forms guide practitioners to more reliably and accurately identify developmental-behavioral conditions such as a “suspected developmental delay”, “higher risk for autism”, “suspected social-emotional/mental health disorder”, or “exposure to domestic violence”.
Whenever a child was previously suspected to have a developmental-behavioral problem, it is helpful to review previous referral reports while tracking the child’s early intervention (EI) and special education eligibility status longitudinally over time.
Act promptly on health-related issues. For these reasons, check boxes are provided to identify common conditions such as “overweight” (BMI > 85th and < 95th %tile), “obesity” (BMI 95th %tile), “underweight” (BMI < 5th %tile), etc.
|AGA||appropriate for gestational age|
|FTT||failure to thrive|
A Special Note about Gathering a History and Assessing the Health Risk of Adolescents (11 to 21 years). HEEADSSS (or HEADS on the well-visit forms) is a mnemonic used to structure the history gathering segment of the adolescent well-visit. Evidence-based measures such as the Eating Disorder Screen for Primary Care (ESP), CRAFFT questionnaire, Pediatric Symptom Checklist-Youth Report (Y-PSC) and 2 evidence-based, suicide-specific questions are embedded into the HEEADSSS format as pre-visit screens to reduce the length of the adolescent interview and leave more time for counseling. Most adolescent morbidity and mortality are related to behavior problems or unhealthy decision-making and, as such, are preventable. The home environment, especially parental involvement and attitudes also affect adolescent behavior and health outcomes and so, these issues are incorporated into the HEEADSSS interview or questionnaire.
This section is meant to work in conjunction with the “Guidance” section that follows. The Plan section includes space to indicate individualized recommendations for services, topics of advice given (e.g., specific information handouts, etc.). The check-off boxes that follow include some of the more common health, developmental-behavioral promotion activities, and service recommendations. (See Chapters 5 and 7 for more information).
For children 6 months to 5 years, strongly consider incorporating Reach Out and Read (ROR) into your practice through which a developmentally age-appropriate book is given at every well-child visit. Although ROR’s milestones checklist is not a substitute for accurate screening, it is a helpful guide to observing parent-child interactions (e.g., it is exciting to walk into an exam room and see parents and children reading together).
Common abbreviations are:
|HS/EHS||Head Start/Early Head Start|
|ECE||Early Childhood program (usually day care or preschool)|
|PO||per os (latin for “by mouth”)|
|ROR||Reach Out and Read|
Guidance (EPSDT Task #4)
This section is meant to work in conjunction with the “Plan” section above and focuses on the most common topics for anticipatory guidance and routine advice to parents given the age of the child.
Immunizations (EPSDT Task # 7)
Check boxes are provided to remind practitioners to give vaccine counseling services (and to code appropriately for reimbursement). Parents of children with developmental disabilities (e.g., autism) tend to intentionally decline immunizations and are therefore, at greater risk of vaccine-preventable illnesses. Appropriate vaccine counseling is commonly needed for parents of children with developmental disabilities (or a positive family history of developmental disabilities).
A box can be checked off whenever the “AAP Refusal to Vaccinate” form has been signed. For parents who intentionally decline vaccinations as recommended by the AAP and Center for Disease Control (CDC), practices should consider having parents sign this form. Abbreviations include:
|EMR/EHR||Electronic Medical Record/Electronic Health Record|
|CDC||Center for Disease Control|
This section also asks practitioners to decide (i.e., “check the box”) if a routinely scheduled visit versus an early return office visit is indicated. For example, in children 0 to 4 years, if a broad-band developmental screen like the ASQ is found to be problematic, then practitioners should consider administering a supplemental social-emotional screening tool like the ASQ:SE. An alternative combination of measures capturing both developmental and social-emotional status is to use a combination of PEDS and the PEDS:DM at an early return office visit (or referring to IDEA services for more detailed assessment). Similarly, when the M-CHAT is found to be positive/problematic, a practitioner should make sure the M-CHAT follow-up interview is completed—either during the current visit, via an early return office visit or most commonly by referral to IDEA programs. If parents do not follow-up with a referral to Early Intervention, then the M-CHAT Follow-up Interview should be conducted at the next return office visit. Follow-up visits, between routinely scheduled well-child encounters, are also needed for monitoring medical conditions (e.g., elevated blood pressure, asthma, etc.).
|ASD||autism spectrum disorder|
Ideally, clinic staff should help parents/caregivers complete measures in advance and enter results into your electronic record or paper encounter form. Staff can also help gather parent/patient information hand-outs and referral information so that it is ready for you before you enter the exam room. A pre-visit screening implementation system helps you to properly interpret screening tool results after your history and physical exam. For information on explaining findings and treatment plans to parents, please see Chapter 8.
*The authors, publisher and editors have taken care to confirm the accuracy of information but are not responsible for errors or omissions or for any consequences arising from the application of content. Deployment of information remains the professional responsibility of practitioners. Nutritive recommendations and vitamin dosing are in accordance with current policy at the time of publication but readers are urged to stay abreast of any new developments given the changing nature of recommendations from the Food and Drug Administration and professional medical societies.