Name: ________________________________
Birthday: ____________________________
| AGE, in years | ||||||||||||||||||||||||
| Medical Issues | At Birth or at Diagnosis |
6-mo | 1 | 1-1/2 | 2 | 2-1/2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20-29 |
| Karotype & Genetic Counseling | _____ | |||||||||||||||||||||||
| Usual Preventative Care |
_____ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ |
| Cardiology | Echo | |||||||||||||||||||||||
| Audiologic Evaluation | ABR or OAE | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ |
| Ophthalmologic Evaluation | Red reflex | _____ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ||
| Thyroid (TSH & T4 |
State screening | _____ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ||
| Nutrition | _____ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ |
| Dental Exam1 | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ||||
| Celiac Screening2 | ___ | |||||||||||||||||||||||
| Parent Support | _____ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ |
| Developmental & Educational Services |
Early Intervention | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ |
| Neck X-rays & Neurological Exam3 | X- ray | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ___ | ||||||
| Pelvic exam4 | ___ | ___ | ___ | ___ | ___ | |||||||||||||||||||
| Assess Contraceptive Need4 | ___ | ___ | ___ | ___ | ___ | |||||||||||||||||||
| Pneumococcal Vaccine | ___ | |||||||||||||||||||||||
Instructions: Perform indicated exam/screening and record date in blank spaces.
1Begin Dental Exams at 2 years of age, and continue every 6 month thereafter.
2IgA antiedomysuim antobodies and total IgA.
3Cervical spine x-rays: flexion, neutral and extension, between 3-5 years of age. Repeat as needed for Special Olympics participation. Neurological examination at each visit.
4If sexually active