Height: (in/cm) Weight: (lbs/kg) Per parent report ☐ Initial Birth Weight: (libs/kg) ☐ ☐ ☐ Level of attention: Appropriate Somewhat distractible Very distractible ☐ Other: ☐ ☐ ☐ Interest in Surroundings: Alert Somewhat disinterested Seriously disinterested ☐ Other: ☐ Behavior: WNL for age Other: DESCRIBE any instances of impulsivity, difficulty following instructions, aggressiveness toward others observed during visit ☐ ☐ ☐ General Appearance: Well-nourished Thin ☐ Other: ☐ ☐ ☐ ☐ Skin: WNL Laceration Bruises Rashes ☐ Other: ☐ ☐ Stool: Toilet trained? Toilet training begun? Last BM: Usual Pattern: Other: ☐ ☐ Bladder: Toilet trained? Toilet training begun Other: ☐ ☐ Muscles: WNL Movement impaired ☐ ☐ ☐ ☐ Adaptive Devices: Eye glasses Hearing Aide Wheelchair ☐ Other:
Height: (in/cm) Weight: (lbs/kg) ☐ Per parent report Initial Birth Weight: (libs/kg) Level of attention: ☐ Appropriate ☐ Somewhat distractible ☐ Very distractible ☐ Other: Interest in Surroundings: ☐ Alert ☐ Somewhat disinterested ☐ Seriously disinterested ☐ Other: Behavior: ☐ WNL for age Other: DESCRIBE any instances of impulsivity, difficulty following instructions, aggressiveness toward others observed during visit General Appearance: ☐ Well-nourished ☐ ☐ Thin ☐ Other: Skin: ☐ WNL ☐ Laceration ☐ Bruises ☐ Rashes ☐ Other: Stool: ☐ Toilet trained? ☐ Toilet training begun? Last BM: Usual Pattern: Other: Bladder: ☐ Toilet trained? ☐ Toilet training begun Other: Muscles: ☐ WNL ☐ Movement impaired ☐ Adaptive Devices: ☐ Eye glasses ☐ Hearing Aide ☐ Wheelchair ☐ Other:
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx