well child visit 4 years old

Ages & Stages

Your checkup checklist: 4 years old.

​​​​​​​​​A 4-year-old engages the world with endless curiosity. Then, they may tell you a story all about it or ask a zillion questions. This is the age of why, what, when and how?

At 4 years old, your child feels "grown up." They typically can get dressed and undressed and go to the bathroom (though they still may not have control at night). They are curious about their bodies and start to want some privacy.

Most kids this age can identify emotions, even nuanced feelings like anxiety and joy, in themselves and others. They comfort others who look sad and like to be helpers. They may respond well to praise and clearly stated rules. But they're also eager to explore boundaries. How far can they walk away from a caregiver before being chased? How many toys can they get away with taking from a sibling ?

Your 4-year-old needs to use up energy by running, climbing, swinging and jumping. But they also need time to rest, play quietly and use their imaginations . Make-believe and dress-up are important for this age. Media and technology have strong appeal and should be used wisely .

What to expect at the 4-year well-child visit

Your 4-year-old will probably participate more in this check-up visit than in the past. The pediatrician will ask them more questions directly. This helps gain your child's cooperation and shows that they've reached some milestones. They may ask if your child brushes their teeth , or what they like to draw or about a favorite story. The doctor will also focus on helping you provide your child a safe, secure ​environment. In addition, they may talk with you about school readiness ,  healthy nutrition and habits,  screen time  and injury prevention .

Here's what else to expect at this visit:

✅ immunizations.

Between the ages of four and six, your child will need several booster shots. They will receive the fifth dose of the DTaP (diphtheria, tetanus, and acellular pertussis), fourth dose of the polio , second dose of the MMR (measles, mumps, and rubella)​ and second dose of the varicella (chickenpox) vaccines.

Your pediatrician will recommend the influenza (flu) vaccine during flu season, and talk about the latest COVID-19 guidelines. You can use these tips​  to make getting a shot less stressful. See " Vaccines Your Child Needs by Age 6 ."

✅ Health Screenings

A full physical exam will be performed along with hearing , vision  and oral health screenings. The vision screening likely will involve an eye chart. The pediatrician also will assess fine and gross motor skills , and observe your child's speech for any difficulties. If a patient is at risk for things like lead exposure or other conditions, your child will be screened for those.

As in last year's visit, pediatricians may take time to address possible needs like having adequate food and being around safe people.​If needed, your doctor can provide community resources offering housing, food and social support.

Questions your pediatrician may ask

Has your child received any specialty or emergency care since the last visit? Or, has your child or anyone in the family developed a new health condition?

Violence has become common in people's lives; do you feel safe in your home?

Can your child go to the bathroom by themselves? Are there any issues around pooping ?

What are your child's likes and dislikes?

Are you concerned about anyone in your home smoking , drinking or using drugs?

✅Developmental Screenings

Your child's play , speech, learning, and movement all are expressions of their growing developmental skills . Most 4-year-olds pretend to be someone or something else, like a teacher or a dog, during play . They can repeat parts of a story or song, and tell you what comes next if they've heard it often. They can answer questions that explain something, like: What is a coat for?

As language skills continue to develop, speech challenges like repetitions of whole words, false starts and stuttering are normal. Never hurry a child to respond because it can increase stuttering. Most  ​outgrow these patterns , but if a child stutters for more than six months, they should be taken for an evaluation.

Children this age can have big feelings , which make them sensitive. They can be easily encouraged or hurt by what others say and do. You can teach your child coping skills by modeling behaviors like apologizing and being respectful of others. Know that nightmares and night terrors are common at this age.

To explore developmental milestones ,  use our motor skills tool . Be sure to share any concerns with your pediatrician. They can offer next steps like a possible referral for further evaluations or an early intervention program.

Does your child understand concepts like "same" and "different?" Can they follow 2- to 3-step instructions?

What do you do when your child is upset?

Can your child get dressed and undressed?

Can they serve themselves food and water?

How is preschool? What does your child like to do there?

Does your child draw a person with three body parts? Can they  ​hold a crayon or pencil ​using fingers and thumb, rather than a fist?

Does your family have a  media use plan ?

Questions you may have

What can I do with my child at this age ?

My child isn't toilet trained . Is that normal ? How about wetting the bed ?

Should I limit screen time ?

What can I do to help calm my child when they're sad or upset?

Is my child ready for school ? Is my child ready to read ?

My child has nightmares . What can I do?

Does my child still need a nap ?

My child is stuttering . Do they need to be evaluated?

✅Feeding & Healthy Nutrition

Like last year, 4-year-olds often have a reduced appetite. That's because they have a slower growth rate at this age. If your child refuses food, they likely aren't hungry. In fact, encouraging a child to eat often means extra unneeded calories. Provide healthy options , especially fruits and vegetables, in appropriate amounts at regular times through the day. Then, let your child decide how much to eat. Minimize foods and drinks high in added sugars​ and saturated fat and low in nutrients. Also, don't prepare substitute foods to entice them to eat because that encourages picky eating .

What did you have for dinner last night?

What snacks do you offer your child?

What does your child drink each day? How much water and milk ?

What should my child be eating ?

My child refuses to drink milk . Does that matter?

What should my child drink ?

My child is picky . What can I do?

The 4-year-old child feels more independent but still needs supervision . They are not ready to cross the street alone, must be watched during outside play, and watched around water. Parents should constantly evaluate the safety of their child's environment. Children should continue to use car seats, using a 5-point harness as long as possible. Most 4-year-olds aren't yet big enough for a booster seat.

Is your community safe for outdoor play?

Do you have a plan for how often your child can use media?

Who watches your child when you cannot?

Is there a firearm in your home or the homes of others where your child might play?

How are you practicing pool and water safety?

When will my child be ready for a booster seat ?

How should I teach my child to safely be around dogs ?

What do I do in a dental emergency ?

✅ Communication Tips

Your pediatrician's top priority is to attend to your concerns. They may refer you to care elsewhere if it is after hours or if a specialist is needed. Pediatricians also can refer you to resources available in your community.

More information

• Safety for Your Child: 2 to 4 Years
• Social Development in Preschoolers
• Creating Positive Experiences With Your Preschooler
• How to Shape & Manage Your Young Child's Behavior
• CDC 4-year-old Milestone Checklist ​

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Doctor Visits

Make the Most of Your Child’s Visit to the Doctor (Ages 1 to 4 Years)

Take Action

Young children need to go to the doctor or nurse for a “well-child visit” 7 times between ages 1 and 4.

A well-child visit is when you take your child to the doctor to make sure they’re healthy and developing normally. This is different from other visits for sickness or injury.

At a well-child visit, the doctor or nurse can help catch any problems early, when they may be easier to treat. You’ll also have a chance to ask questions about things like your child’s behavior, eating habits, and sleeping habits.

Learn what to expect so you can make the most of each visit.

Well-Child Visits

How often do i need to take my child for well-child visits.

Young children grow quickly, so they need to visit the doctor or nurse regularly to make sure they’re healthy and developing normally.

Children ages 1 to 4 need to see the doctor or nurse when they’re:

• 12 months old
• 15 months old (1 year and 3 months)
• 18 months old (1 year and 6 months)
• 24 months old (2 years)
• 30 months old (2 years and 6 months)
• 3 years old
• 4 years old

If you’re worried about your child’s health, don’t wait until the next scheduled visit — call the doctor or nurse right away.

Child Development

How do i know if my child is growing and developing on schedule.

Your child’s doctor or nurse can help you understand how your child is developing and learning to do new things — like walk and talk. These are sometimes called  “developmental milestones.”

Every child grows and develops differently. For example, some children will take longer to start talking than others. Learn more about child development .

At each visit, the doctor or nurse will ask you how you’re doing as a parent and what new things your child is learning to do.

Ages 12 to 18 Months

By age 12 months, most kids:.

• Stand by holding on to something
• Walk with help, like by holding on to the furniture
• Call a parent "mama," "dada," or some other special name
• Look for a toy they've seen you hide

Check out this complete list of milestones for kids age 12 months .

By age 15 months, most kids:

• Follow simple directions, like "Pick up the toy"
• Show you a toy they like
• Try to use things they see you use, like a cup or a book
• Take a few steps on their own

Check out this complete list of milestones for kids age 15 months.

By age 18 months, most kids:

• Make scribbles with crayons
• Look at a few pages in a book with you
• Try to say 3 or more words besides “mama” or “dada”
• Point to show someone what they want
• Walk on their own
• Try to use a spoon

Check out this complete list of milestones for kids age 18 months . 

Ages 24 to 30 Months

By age 24 months (2 years), most kids:.

• Notice when others are hurt or upset
• Point to at least 2 body parts, like their nose, when asked
• Try to use knobs or buttons on a toy
• Kick a ball

Check out this complete list of milestones for kids age 24 months . 

By age 30 months, most kids:

• Name items in a picture book, like a cat or dog
• Play simple games with other kids, like tag
• Jump off the ground with both feet
• Take some clothes off by themselves, like loose pants or an open jacket

Check out this complete list of milestones for kids age 30 months .

Ages 3 to 4 Years

By age 3 years, most kids:.

• Calm down within 10 minutes after you leave them, like at a child care drop-off
• Draw a circle after you show them how
• Ask “who,” “what,” “where,” or “why” questions, like “Where is Daddy?”

Check out this complete list of milestones for kids age 3 years . 

By age 4 years, most kids:

• Avoid danger — for example, they don’t jump from tall heights at the playground
• Pretend to be something else during play, like a teacher, superhero, or dog
• Draw a person with 3 or more body parts
• Catch a large ball most of the time

Check out this complete list of milestones for kids age 4 years . 

Take these steps to help you and your child get the most out of well-child visits.

Gather important information.

Bring any medical records you have to the appointment, including a record of vaccines (shots) your child has received.

Make a list of any important changes in your child’s life since the last doctor’s visit, like a:

• New brother or sister
• Serious illness or death in the family
• Separation or divorce
• Change in child care

Use this tool to  keep track of your child’s family health history .

Ask other caregivers about your child.

Before you visit the doctor, talk with others who care for your child, like a grandparent, daycare provider, or babysitter. They may be able to help you think of questions to ask the doctor or nurse.

What about cost?

Under the Affordable Care Act, insurance plans must cover well-child visits. Depending on your insurance plan, you may be able to get well-child visits at no cost to you. Check with your insurance company to find out more.

Your child may also qualify for free or low-cost health insurance through Medicaid or the Children’s Health Insurance Program (CHIP). Learn about coverage options for your family.

If you don’t have insurance, you may still be able to get free or low-cost well-child visits. Find a health center near you and ask about well-child visits.

To learn more, check out these resources:

• Free preventive care for children covered by the Affordable Care Act
• How the Affordable Care Act protects you and your family
• Understanding your health insurance and how to use it [PDF - 698 KB]

Ask Questions

Make a list of questions you want to ask the doctor..

Before the well-child visit, write down 3 to 5 questions you have. This visit is a great time to ask the doctor or nurse any questions about:

• A health condition your child has (like asthma or an allergy)
• Changes in sleeping or eating habits
• How to help kids in the family get along

Here are some questions you may want to ask:

• Is my child up to date on vaccines?
• How can I make sure my child is getting enough physical activity?
• Is my child at a healthy weight?
• How can I help my child try different foods?
• What are appropriate ways to discipline my child?
• How much screen time is okay for young children?

Take a notepad, smartphone, or tablet and write down the answers so you remember them later.

Ask what to do if your child gets sick. 

Make sure you know how to get in touch with a doctor or nurse when the office is closed. Ask how to get hold of the doctor on call — or if there's a nurse information service you can call at night or during the weekend. 

What to Expect

Know what to expect..

During each well-child visit, the doctor or nurse will ask you questions about your child, do a physical exam, and update your child's medical history. You'll also be able to ask your questions and discuss any problems you may be having.

The doctor or nurse will ask questions about your child.

The doctor or nurse may ask about:

• Behavior — Does your child have trouble following directions?
• Health — Does your child often complain of stomachaches or other kinds of pain?
• Activities — What types of pretend play does your child like?
• Eating habits — What does your child eat on a normal day?
• Family — Have there been any changes in your family since your last visit?

They may also ask questions about safety, like:

• Does your child always ride in a car seat in the back seat of the car? 
• Does anyone in your home have a gun? If so, is it unloaded and locked in a place where your child can’t get it?
• Is there a swimming pool or other water around your home?
• What steps have you taken to childproof your home? Do you have gates on stairs and latches on cabinets?

Your answers to questions like these will help the doctor or nurse make sure your child is healthy, safe, and developing normally.

Physical Exam

The doctor or nurse will also check your child’s body..

To check your child’s body, the doctor or nurse will:

• Measure your child’s height and weight
• Check your child’s blood pressure
• Check your child’s vision
• Check your child’s body parts (this is called a physical exam)
• Give your child shots they need

Learn more about your child’s health care:

• Find out how to get your child’s shots on schedule
• Learn how to take care of your child’s vision

Content last updated February 2, 2024

Reviewer Information

This information on well-child visits was adapted from materials from the Centers for Disease Control and Prevention and the National Institutes of Health.

Reviewed by: Sara Kinsman, M.D., Ph.D. Director, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

Bethany Miller, M.S.W. Chief, Adolescent Health Branch Maternal and Child Health Bureau Health Resources and Services Administration

Diane Pilkey, R.N., M.P.H. Nursing Consultant, Division of Child, Adolescent, and Family Health Maternal and Child Health Bureau Health Resources and Services Administration

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Well Child Visit at 4 Years

Medically reviewed by Drugs.com. Last updated on Apr 2, 2024.

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What is a well child visit?

A well child visit is when your child sees a healthcare provider to prevent health problems. Well child visits are used to track your child's growth and development. It is also a time for you to ask questions and to get information on how to keep your child safe. Write down your questions so you remember to ask them. Your child should have regular well child visits from birth to 17 years.

What development milestones may my child reach by 4 years?

Each child develops at his or her own pace. Your child might have already reached the following milestones, or he or she may reach them later:

• Speak clearly and be understood easily
• Know his or her first and last name and gender, and talk about his or her interests
• Identify some colors and numbers, and draw a person who has at least 3 body parts
• Tell a story or tell someone about an event, and use the past tense
• Hop on one foot, and catch a bounced ball
• Enjoy playing with other children, and play board games
• Dress and undress himself or herself, and want privacy for getting dressed
• Control his or her bladder and bowels, with occasional accidents

What can I do to keep my child safe in the car?

• Always put your child's car seat in the back seat. Never put your child's car seat in the front. This will help prevent him or her from being injured in an accident.

What can I do to make my home safe for my child?

• Place guards over windows on the second floor or higher. This will prevent your child from falling out of the window. Keep furniture away from windows. Use cordless window shades, or get cords that do not have loops. You can also cut the loops. A child's head can fall through a looped cord, and the cord can become wrapped around his or her neck.
• Secure heavy or large items. This includes bookshelves, TVs, dressers, cabinets, and lamps. Make sure these items are held in place or nailed into the wall.
• Store and lock all guns and weapons. Make sure all guns are unloaded before you store them. Make sure your child cannot reach or find where weapons or bullets are kept. Never leave a loaded gun unattended.

What can I do to keep my child safe in the sun and near water?

• Always keep your child within reach near water. This includes any time you are near ponds, lakes, pools, the ocean, or the bathtub.
• Ask about swimming lessons for your child. At 4 years, your child may be ready for swimming lessons. He or she will need to be enrolled in lessons taught by a licensed instructor.
• Put sunscreen on your child. Ask your healthcare provider which sunscreen is safe for your child. Do not apply sunscreen to your child's eyes, mouth, or hands.

What are other ways I can keep my child safe?

• Follow directions on the medicine label when you give your child medicine. Ask your child's healthcare provider for directions if you do not know how to give the medicine. If your child misses a dose, do not double the next dose. Ask how to make up the missed dose. Do not give aspirin to children younger than 18 years. Your child could develop Reye syndrome if he or she has the flu or a fever and takes aspirin. Reye syndrome can cause life-threatening brain and liver damage. Check your child's medicine labels for aspirin or salicylates.
• Talk to your child about personal safety without making him or her anxious. Teach him or her that no one has the right to touch his or her private parts. Also explain that others should not ask your child to touch their private parts. Let your child know that he or she should tell you even if he or she is told not to.
• Do not let your child play outdoors without supervision from an adult. Your child is not old enough to cross the street on his or her own. Do not let him or her play near the street. He or she could run or ride his or her bicycle into the street.

What do I need to know about nutrition for my child?

• Whole grains such as bread, hot or cold cereal, and cooked pasta or rice
• Protein from lean meats, chicken, fish, beans, or eggs
• Dairy such as whole milk, cheese, or yogurt
• Vegetables such as carrots, broccoli, or spinach
• Fruits such as strawberries, oranges, apples, or tomatoes
• Limit foods high in fat and sugar. These foods do not have the nutrients your child needs to be healthy. Food high in fat and sugar include snack foods (potato chips, candy, and other sweets), juice, fruit drinks, and soda. If your child eats these foods often, he or she may eat fewer healthy foods during meals. He or she may gain too much weight.
• Do not give your child foods that could cause him or her to choke. Examples include nuts, popcorn, and hard, raw vegetables. Cut round or hard foods into thin slices. Grapes and hotdogs are examples of round foods. Carrots are an example of hard foods.
• Give your child 3 meals and 2 to 3 snacks per day. Cut all food into small pieces. Examples of healthy snacks include applesauce, bananas, crackers, and cheese.

What can I do to keep my child's teeth healthy?

• Your child needs to brush his or her teeth with fluoride toothpaste 2 times each day. He or she also needs to floss 1 time each day. Have your child brush his or her teeth for at least 2 minutes. At 4 years, your child should be able to brush his or her teeth without help. Apply a small amount of toothpaste the size of a pea on the toothbrush. Make sure your child spits all of the toothpaste out. Your child does not need to rinse his or her mouth with water. The small amount of toothpaste that stays in his or her mouth can help prevent cavities.
• Take your child to the dentist regularly. A dentist can make sure your child's teeth and gums are developing properly. Your child may be given a fluoride treatment to prevent cavities. Ask your child's dentist how often he or she needs to visit.

What can I do to create routines for my child?

• Have your child take at least 1 nap each day. Plan the nap early enough in the day so your child is still tired at bedtime.
• Create a bedtime routine. This may include 1 hour of calm and quiet activities before bed. You can read to your child or listen to music. Have your child brush his or her teeth during his or her bedtime routine.
• Plan for family time. Start family traditions such as going for a walk, listening to music, or playing games. Do not watch TV during family time. Have your child play with other family members during family time.

What else can I do to support my child?

• Do not punish your child with hitting, spanking, or yelling. Never shake your child. Tell your child "no." Give your child short and simple rules. Do not allow your child to hit, kick, or bite another person. Put your child in time-out in a safe place. You can distract your child with a new activity when he or she behaves badly. Make sure everyone who cares for your child disciplines him or her the same way.
• Help your child get ready to go to school. Your child's healthcare provider may help you create meal, play, and bedtime schedules. Your child will need to be able to follow a schedule before he or she can start school. You may also need to make sure your child can go to the bathroom on his or her own and wash his or her own hands.
• Talk with your child. Have him or her tell you about his or her day. Ask him or her what he or she did during the day, or if he or she played with a friend. Ask what he or she enjoyed most about the day. Have him or her tell you something he or she learned.
• Help your child learn outside of school. Take him or her to places that will help him or her learn and discover. For example, a children's museum will allow him or her to touch and play with objects as he or she learns. Your child may be ready to have his or her own library card. Let him or her choose his or her own books to check out from the library. Teach him or her to take care of the books and to return them when he or she is done.
• Talk to your child's healthcare provider about bedwetting. Bedwetting may happen up to the age of 4 years in girls and 5 years in boys. Talk to your child's healthcare provider if you have any concerns about this.
• Engage with your child if he or she watches TV. Do not let your child watch TV alone, if possible. You or another adult should watch with your child. Talk with your child about what he or she is watching. When TV time is done, try to apply what you and your child saw. For example, if your child saw someone talking about colors, have your child find objects that are those colors. TV time should never replace active playtime. Turn the TV off when your child plays. Do not let your child watch TV during meals or within 1 hour of bedtime.
• Limit your child's screen time. Screen time is the amount of television, computer, smart phone, and video game time your child has each day. It is important to limit screen time. This helps your child get enough sleep, physical activity, and social interaction each day. Your child's pediatrician can help you create a screen time plan. The daily limit is usually 1 hour for children 2 to 5 years. The daily limit is usually 2 hours for children 6 years or older. You can also set limits on the kinds of devices your child can use, and where he or she can use them. Keep the plan where your child and anyone who takes care of him or her can see it. Create a plan for each child in your family. You can also go to https://www.healthychildren.org/English/media/Pages/default.aspx#planview for more help creating a plan.

What do I need to know about my child's next well child visit?

Your child's healthcare provider will tell you when to bring him or her in again. The next well child visit is usually at 5 to 6 years. Contact your child's healthcare provider if you have questions or concerns about your child's health or care before the next visit. All children aged 3 to 5 years should have at least one vision screening. Your child may need vaccines at the next well child visit. Your provider will tell you which vaccines your child needs and when your child should get them.

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Learn more about Well Child Visit at 4 Years

Care guides.

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• Gender Identity in Adolescents
• Gender Identity in your Adolescent
• Hemoglobin A1c
• Hepatitis B in Children
• Hepatitis B Vaccine
• How to Childproof your Home

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Bright Futures Information for Parents: 4 Year Visit

Here are some suggestions from Bright Futures experts that may be of value to your family.​​

How Your Family Is Doing

Stay involved in your community. Join activities when you can.

If you are worried about your living or food situation, talk with us. Community agencies and programs such as WIC and SNAP can also provide information and assistance.

Don’t smoke or use e-cigarettes. Keep your home and car smoke-free. Tobacco-free spaces keep children healthy.

Don’t use alcohol or drugs.

If you feel unsafe in your home or have been hurt by someone, let your health care professional​ know. Hotlines and community agencies can also provide confidential help.

Teach your child about how to be safe in the community.

• Use correct terms for all body parts as your child becomes interested in how boys and girls differ.
• No adult should ask a child to keep secrets from parents.
• No adult should ask to see a child’s private parts.
• No adult should ask a child for help with the adult’s own private parts.

​Getting Ready For School

Give your child plenty of time to finish sentences.

Read books together each day and ask your child questions about the stories.

Take your child to the library and let him choose books.

Listen to and treat your child with respect. Insist that others do so as well.

Model saying you’re sorry and help your child to do so if he hurts someone’s feelings.

Praise your child for being kind to others.

Help your child express his feelings.

Give your child the chance to play with others often.

Visit your child’s preschool or child care program. Get involved.

Ask your child to tell you about his day, friends, and activities.

Healthy Habits

Give your child 16 to 24 oz of milk every day.

Limit juice. It is not necessary. If you choose to serve juice, give no more than 4 oz a day of 100%juice and always serve it with a meal.

Let your child have cool water when she is thirsty.

Offer a variety of healthy foods and snacks, especially vegetables, fruits, and lean protein.

Let your child decide how much to eat.

Have relaxed family meals without TV.

Create a calm bedtime routine.

Have your child brush her teeth twice each day. Use a pea-sized amount of toothpaste with fluoride.

TV and Media

Be active together as a family often.

Limit TV, tablet, or smartphone use to no more than 1 hour of high-quality programs each day.

Discuss the programs you watch together as a family.

Consider making a family media plan. It helps you make rules for media use and balance screen time with other activities, including exercise.

Don’t put a TV, computer, tablet, or smartphone in your child’s bedroom.

Create opportunities for daily play.

Praise your child for being active.

Use a forward-facing car safety seat or switch to a belt-positioning booster seat when your child reaches the weight or height limit for her car safety seat, her shoulders are above the top harness slots, or her ears come to the top of the car safety seat.

The back seat is the safest place for children to ride until they are 13 years old.

Make sure your child learns to swim and always wears a life jacket. Be sure swimming pools are fenced.

When you go out, put a hat on your child, have her wear sun protection clothing, and apply sunscreen with SPF of 15 or higher on her exposed skin. Limit time outside when the sun is strongest (11:00 am–3:00 pm).

If it is necessary to keep a gun in your home, store it unloaded and locked with the ammunition locked separately.

Ask if there are guns in homes where your child plays. If so, make sure they are stored safely.

What to Expect at Your Child's 5 and 6 Year Visit

We will talk about:

• Taking care of your child, your family, and yourself
• Creating family routines and dealing with anger and feelings
• Preparing for school
• Keeping your child’s teeth healthy, eating healthy foods, and staying active
• Keeping your child safe at home, outside, and in the car

Helpful Resources:

• National Domestic Violence Hotline: 800-799-7233
• Family Media Use Plan: www.healthychildren.org/MediaUsePlan
• Smoking Quit Line: 800-784-8669
• Information About Car Safety Seats: www.nhtsa.gov/parents-and-caregivers
• Toll-free Auto Safety Hotline: 888-327-4236

Consistent with Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition

The information contained in this webpage should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances. Original handout included as part of the Bright Futures Tool and Resource Kit, 2nd Edition.

Inclusion in this webpage does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of the resources mentioned in this webpage. Website addresses are as current as possible but may change at any time.

The American Academy of Pediatrics (AAP) does not review or endorse any modifications made to this handout and in no event shall the AAP be liable for any such changes.

Last Updated

American Academy of Pediatrics

Important Milestones: Your Child By Four Years

CDC’s milestones and parent tips have been updated and new checklist ages have been added (15 and 30 months). For more information about the updates to CDC’s developmental milestones, please review the Pediatrics journal article  and these  important key points .

How your child plays, learns, speaks, acts, and moves offers important clues about your child’s development. Developmental milestones are things most children (75% or more) can do by a certain age.

Check the milestones your child has reached by 4 years by completing a checklist with CDC’s free Milestone Tracker  mobile app, for  iOS  and  Android  devices, using the Digital Online Checklist , or by printing the checklist [755 KB, 2 Pages, Print Only]  below.

“Learn the Signs. Act Early.” materials are not a substitute for standardized, validated developmental screening tools .

What most children do by this age:

Social/emotional milestones.

Close this video

Language/Communication Milestones

Cognitive milestones (learning, thinking, problem-solving), movement/physical development milestones, comforts others who are hurt or sad, like hugging a crying friend.

Draws a person with three or more body parts

Catches a large ball most of the time

1 of 2 images

2 of 2 images

Serves herself food or pours water, with adult supervision

Holds crayon or pencil between fingers and thumb (not a fist)

Other important things to share with the doctor…

• What are some things you and your baby do together?
• What are some things your baby likes to do?
• Is there anything your baby does or does not do that concerns you?
• Has your baby lost any skills he/she once had?
• Does your baby have any special healthcare needs or was he/she born prematurely?

Concerned About Your Child’s Development? Act Early.

You know your child best. Don’t wait. If your child is not meeting one or more milestones, has lost skills he or she once had, or you have other concerns, act early. Talk with your child’s doctor, share your concerns, and ask about developmental screening.

If you or the doctor are still concerned:

• Ask for a referral to a specialist who can evaluate your child more; and
• Call your state or territory’s early intervention program to find out if your child can get services to help. Learn more and find the number at cdc.gov/FindEI .

For more on how to help your child, visit cdc.gov/Concerned .

As your child’s first teacher, you can help his or her learning and brain development. Try these simple tips and activities in a safe way. Talk with your child’s doctor and teachers if you have questions or for more ideas on how to help your child’s development.

• Help your child be ready for new places and meeting new people. For example, you can read stories or role play (pretend play) to help him be comfortable.
• Read with your child. Ask him what’s happening in the story and what he thinks might happen next.
• Help your child learn about colors, shapes, and sizes. For example, ask the color, shapes, and size of things she sees during the day.

Click here for more tips and activities

• Encourage your child to use “his words” to ask for things and solve problems but show him how. He may not know the words he needs. For example, help your child say, “Can I have a turn?” instead of taking something from someone.
• Help your child learn about others’ feelings, and about positive ways to react. For example, when he sees a child who is sad, say “He looks sad. Let’s bring him a teddy.”
• Use positive words and give attention to behaviors you want to see (“wanted behaviors”). For example, say “You’re sharing that toy so nicely!” Give less attention to those you don’t want to see.
• Tell your child in a simple way why she can’t do something you don’t want her to do (“unwanted behavior”). Give her a choice of what she can do instead. For example, “You can’t jump on the bed. Do you want to go outside and play or put on some music and dance?”
• Let your child play with other children, such as at a park or library. Ask about local play groups and pre-school programs. Playing with others helps you child learn the value of sharing and friendship.
• Eat meals with your child when possible. Let her see you enjoying healthy foods, such as fruits, vegetables, and whole grains, and drinking milk or water.
• Create a calm, quiet bedtime routine. Avoid any screen time (TV, phone, tablet, etc.) for 1 to 2 hours before bed and don’t put any screens in your child’s bedroom. Children this age need 10 to 13 hours of sleep a day (including naps). Consistent sleep times make it easier!
• Give your child toys or things that encourage his imagination, such as dress-up clothes, pots and pans to pretend cook, or blocks to build with. Join him in pretend play, such as eating the pretend food he cooks.
• Take time to answer your child’s “why” questions. If you don’t know the answer, say “I don’t know,” or help your child find the answer in a book, on the Internet, or from another adult.
• Count simple things, such as fingers, toys, or bananas. This will help your child learn about numbers and counting.
• Give your child choices that are simple and healthy. Let her choose what to wear, play, or eat for a snack. Limit choices to 2 or 3.
• Continue to teach your child skills to play with others, such as using words, sharing toys, and taking turns.
• Teach your child to play outdoor games with friends, such as tag, follow the leader, and hide and seek.
• Spend time speaking to your child in complete sentences, using “grown-up” words. This will help her learn better speaking skills and helps with future reading and writing skills.
• Let your child help with simple chores, such as bringing in the mail, feeding a pet, or wiping down tables. This helps build independence.
• Teach your child to stop and wait when excited by playing red light, green light, or freeze dance (play music, turn it off, and have everyone freeze when it stops).
• Play your child’s favorite songs and dance with your child. Take turns copying each other’s moves.
• Give your child time to solve her own problems with friends. For example, if they are arguing over who gets to be which superhero, let them work it out. Stay nearby to help if needed. If they can’t work it out, use questions to help them think of other solutions.
• Use words, such as “first,” “second,” and “finally.” When playing, telling stories, or doing chores, ask your child what comes next. This will help your child learn about the order of events.
• Comfort your child if he is afraid and talk about his fears. For example, “Monsters can feel scary even though they are not real and can’t hurt you.” Help your child learn things he can do when he is afraid, such as hugging a stuffed animal.
• Play simple games, such as Tic-Tac-Toe or matching games.
• Try to make time for active play each day. Your child will have more fun if she can choose the activity. For example, give her choices, such as playing music and dancing together, playing outside, or taking a walk together.
• Help your child notice when he hurts someone’s feelings by describing what you see. Encourage him to say sorry and help him find a way to make the person feel better.
• Take trips to the library to let your child pick out books.
• Limit screen time (TV, tablets, phones, etc.) to no more than 1 hour per day of a children’s program with an adult present. Don’t put any screens in your child’s bedroom. Children learn by talking, playing, and interacting with others.

Special acknowledgments to the subject matter experts and others who contributed to the review of data and selection of developmental milestones, especially Paul H. Lipkin, MD, Michelle M. Macias, MD, Julie F. Pajek, PhD, Judith S. Shaw, EdD, MPH, RN, Karnesha Slaughter, MPH, Jane K. Squires,  PhD, Toni M. Whitaker, MD, Lisa D. Wiggins, PhD, and Jennifer M. Zubler, MD.

Sincere gratitude to Natalia Benza, MD and José O. Rodríguez, MD, MBA for their thoughtful review of the Spanish-language translation of these milestones.

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4-Year-Old Well Child Check

The four-year-old is more of everything. expansive and extreme, wild and wonderful, energetic, ridiculous and silly..

She likes new things, is a nonconformist, a free thinker, and a very fast study. This year you may ask yourself in wonder, "What in the world did I do to have a child like this?" The answer is, there's nothing much you could or can do; your child is just being four!

Four-year-olds can strut around and brag about how great they are during the day, and then wake up at night from a bad dream and suck their thumbs. Be careful that they don't fool you, they seem to be older than they really are. For all their exhibitionist behavior and aggressiveness, the four-year-old can understand and respond very well to limits. Although they act more independent, they are aware of criticism and thrive on praise and support.

A four-year-old is apt to open a conversation with his name, age, and address. After that, he can talk up a storm, using as many as 2000 words by the end of the year, and using them well. Ask him the difference between a penny, a nickel, and a dime, and he may know that plus the alphabet and his numbers.

He's fun to talk to, because his sentences may be as long as six words, and he's beginning to use plurals correctly, but his word endings aren't quite right yet. He's absolutely fascinated with the world around him, and his "how," "why," "when," questions are the way he's trying to make sense of it all.

Body Control

Four-year-olds have a lot of energy, and they move fast. They can climb like monkeys, and hang upside down. They can swing all by themselves, do somersaults, hop, skip, and jump. Because their balance is better, they are good at riding tricycles. They can play ball and do gymnastics, and get carried away with their newly developed body control that they often take too many chances. Your four-year-old will develop better hand control too, and may be able to button, lace her shoes, and string smaller beads. She can use tools, paint with a brush, and use scissors. She may be trying to print her name, but fine motor tasks are at the beginning stages, so praise her efforts, but don't expect perfect control. When she eats, it's with a fork and spoon, and afterwards she can (and should) brush her teeth.

Development

• Hops and stands on one foot up to five seconds
• Goes upstairs and downstairs without support
• Kicks ball forward

Hand And Finger Skills

• Copies square shapes
• Draws a person with two to four body parts
• Uses scissors
• Speaks in sentences of five to six words
• Speaks clearly enough for strangers to understand
• Increasingly inventive in fantasy play
• Dresses and undresses
• More independent
• Often cannot distinguish between fantasy and reality
• Can express anger verbally rather than physically (most of the time)
• Still throws occasional tantrums over minor frustrations

Growth And Nutrition

Daily nutritional guide for the 4 to 6 year old

Grains -  6-11 servings/day

• Bread, ½ slice
• Cereal, rice, pasta cooked, 1/3 cup
• Cereal, dry ½ cup
• Crackers, 3 to 4

Vegetables - 2-3 servings/day

• Vegetables, cooked or canned ¼ cup
• Salad, ½ cup

Fruits - 2-3 servings/day

• Fruit, cooked or canned, ¼ cup
• Fruit, fresh, ½ piece
• Juice, 1/3 cup

Dairy- 2-3 servings/day

• Milk (does not have to be whole) ½ cup
• Cheese, 1 ounce
• Yogurt, ½ cup

Meats and Proteins - 2 servings/day

• Meat, fish, poultry, tofu, 1 ounce (2 1 inch cubes)
• Beans, dried, cooked, 1/3 cup

Calcium 1000 mg/day

Keep snacks healthy, encourage drinking water and keep juice to a minimum.

Common Issues And Concerns

This year or next year, your child's conscience will emerge. The conscience acts as a stand-in for the parent, an internal voice that will tell him what is "right" and "wrong" in terms of behavior. To effectively discipline your child, you need to be firm, and explain to the child what he did wrong. Make your punishment "fit the crime," be concise, and be "immediate." Two key elements to good discipline are consistency and balance. Be sure you disapprove of the same thing tomorrow that you punished for today. Also, when you catch your child doing something well or right, praise him so he doesn't get only negative messages.

It is important to read to you child. Children not only love to be read to, but the story and fairy tales assist kids in working through their own fantasies, conflicts, and experimentation with roles. If children are read to at home, they will do better in school, have more complex vocabularies, and ask more complex questions. A good screening tool to assess your child's pre-reading skills can be found at Get Ready to Read!

Even though your child is older now, it's important to realize that until age seven, television and movies are risky business. Because your child still can't differentiate between reality and fantasy, certain scenes, even in classic family entertainment movies, can terrify her and cause nightmares. Studies have shown that although children can learn from imitating television, they do not learn to think or solve problems. It's been proven that children who watch hours of television every day lag behind their peers in development. Remember, children can't set their own limits.

Common Health Concerns

Stomachaches.

Stomachaches are very common in four-year-olds and five-year-olds, especially in girls. If your child complains of recurrent stomachaches, see if you can find a pattern to them. Do they happen in the morning before she goes to preschool, for example, and not on Saturday or Sunday when she's home? If so, they may be her way to express anxiety.

If your child has a stomachache, quiet her and feel her abdomen for tenderness. If she has sharp pains in one area, pain which gets worse as time goes on, no bowel movements, vomiting, or a hard "rocklike" stomach, call our office immediately.

A child first complains of headaches at about the age of four; early morning and late in the afternoon are common times. Sometimes mild headaches are a form of resistance to pressures on the child or low blood sugar, and will respond to rest or a glass of juice. As a parent, it would be a good idea to note on your calendar when headaches occur so you can see if there is a common cause. If headaches become worse over time or occur more often, and if other symptoms surface like eye problems, stomach problems, or weakness, call our office.

Because your four-year-old is a risk-taker, accidents can happen easily. Accidents are most common when the child is tired and hungry, when he's in a new environment, or when new people are caring for him. If you are pregnant, ill, having trouble with your spouse, rushed, or too busy, an accident could happen. Be sure you know the stage of development your child is in, so you can anticipate new risks.

At four, your child should have a good set of safety guidelines; rules for riding a tricycle, crossing the street, playing on the playground, and swimming. Accidents will happen, and to deal with the unexpected, you should know some first aid. 

For further information on safety, you may also visit Healthychildren.org .

Next Well Child Visit

The next routine physical examination is at five years of life.

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Home > What to Expect at a Preschooler Well Check at 4 Years Old

What to Expect at a Preschooler Well Check at 4 Years Old

As children grow they reach new physical and developmental milestones. Preschool and school-aged kids’ well visits are essential for tracking this progress and identifying any areas of concern. Parents often have many questions when their child reaches the age of four, and a Cumming checkup is the perfect opportunity to receive advice and guidance from an experienced pediatrician.

A Guide to Preschool Well Checks at Age 4

At four years old, a checkup evaluates a child’s physical health, cognitive skills, social development and emotional well-being. When a child is not reaching their developmental milestones, it’s vital that they receive the help they need and that the family is supported. Here are some of the many elements a pediatrician will focus on during the visit.

Nutritional Guidelines for a 4-Year-Old Child

A 4-year-old’s interest in eating may be unpredictable and erratic from meal to meal, but overall consumption is fairly constant. Children this age may have a limited attention span at the table and they tend to eat following a pattern similar to adults but are not capable of choosing a well-balanced diet.

Your Preschooler’s School Readiness

Observing your child’s interactions with others offers valuable insights into their social skills and understanding. To set a good example in the home, it’s important to listen to your child and treat them with respect. Modeling respectful behavior and apologizing when necessary teaches your child valuable lessons in social conduct and empathy. You can also reinforce positive behaviors by praising your child when they show consideration for the feelings of others.

Encouraging your child to express a range of emotions like joy, anger, sadness, fear and frustration is key to their emotional development. Social development can also be bolstered through play with peers in preschool or playgroups. Also, engage in fun activities together to further strengthen the parent-child bond.

Reading is another important aspect of school readiness. Reading together builds a love for literature, while also enhancing curiosity and comprehension skills. Make sure to ask questions about the story, and encourage your child to explore letters and sounds, including rhymes with real and nonsense words. And to further broaden their understanding of the world, take regular trips to parks and libraries.

The development of language skills can be nurtured by encouraging your child to talk about their day, friends and observations. To prevent stuttering, give them time to tell stories or respond to questions. These practices will prepare your child for school and lay a foundation for lifelong learning and development. Also, if you identify an issue with communication, your pediatrician can provide help on child development areas requiring attention.

8 Healthy Habits for Your Preschooler

• Create a calm bedtime ritual that includes reading or telling stories.
• Create a pleasant atmosphere at mealtimes by turning off the TV and having table conversation that includes your child.
• Be sure that your child brushes his or her teeth twice a day with a pea-sized amount of fluoridated toothpaste. They should spit out the toothpaste after brushing. Supervise tooth brushing each time. Follow up with your pediatric dentist every six months.
• Limit television and video viewing to no more than 2 hours per day. Be sure the programs are appropriate. If you allow your child to watch TV, watch with them and talk together about the programs.
• Encourage your child to be active in many ways, including running, marching, and jumping.
• As often as possible, be physically active as a family. Go on walks, play in the park or on a safe street, or ride bikes.
• Anticipate your child’s normal curiosity about his body and the differences between boys and girls.
• Use correct terms for all body parts, including genitals.

Safety Concerns With a 4-Year-Old Preschooler

Ensuring your four-year-old’s safety is multifaceted. For car travel, use a size-appropriate, forward-facing car safety seat that’s correctly installed in the back seat. To learn more, visit the Child Safety Seat Inspection Station Locator at www.seatcheck.org (or call 866-SEATCHECK). Always remember that the back seat is the safest for children.

Supervise your child closely, especially outdoors and near streets or driveways, as they’re not ready to safely navigate these areas alone. Also, teach them about body safety, explaining that areas covered by a bathing suit are private and should not be touched by others without consent.

Teaching Your Child About Personal Safety and Trust

Educating your child about personal safety is important, particularly as potential abusers can be trusted individuals. To keep it simple, focus on three essential rules for interacting with adults. First, an adult should never tell a child to keep secrets from their parents. Second, adults should not show interest in a child’s private parts. Third, adults should not seek a child’s help with their own private areas. These guidelines emphasize the need for open communication with family members and help your child identify inappropriate behaviors.

Gun Safety and Protecting Your Child

The easiest way to prevent gun-related injuries or deaths in children is to not have a firearm in the home. If you do own firearms, remember that very young children might not comprehend their dangers. Always store guns unloaded and locked away, keeping ammunition separate. It’s also important to check whether a home your child visits stores firearms in a similarly safe manner. These steps help create a secure environment for your child at home and elsewhere.

Contact Us for Well Check Visits for Children in Cumming

At Vickery Pediatrics we provide well-child visits for infants, toddlers, preschoolers and school-aged children. If you are located in Cumming, Buford, Dawsonville, Gainesville, Johns Creek, Sugar Hill, Suwanee, Forsyth County or the surrounding areas, contact us today. Call (678) 990-2501 or request an appointment now .

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KENNETH W. LIN, MD, MPH, Georgetown University School of Medicine, Washington, District of Columbia

Am Fam Physician. 2015;91(6):362-364

More than two-thirds of practicing family physicians report that they provide care for children, 1 and well-child visits provide the best opportunities to deliver evidence-based preventive services. These services include administering immunizations, assessing growth and development, and counseling children and parents about behavioral issues, nutrition, exercise, and prevention of unintentional injury. 2

The American Academy of Pediatrics (AAP) recently updated its recommendations on preventive health care for children, 3 which define a set of services that, under the Affordable Care Act, must be covered by Medicaid and private insurers at no out-of-pocket cost. 4 The current AAP Bright Futures guideline (available at http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf ) includes three screening tests that were not recommended for all children in previous versions: autism screening at 18 and 24 months of age, cholesterol screening between nine and 11 years of age, and annual screening for high blood pressure beginning at three years of age.

It should be noted that none of these screening tests are included in the American Academy of Family Physicians' (AAFP's) list of recommended preventive services for children ( Table 1 ) . 5 The AAFP's clinical preventive services recommendations are generally consistent with those of the U.S. Preventive Services Task Force (USPSTF). The USPSTF methods for developing recommendations include performing a systematic evidence review of the benefits and harms of a preventive service, and recommending that the service be provided to the general population only after consistent data from high-quality randomized controlled trials or other prospective studies establish that the benefits exceed the harms. 6 This rigorous approach to the development of clinical practice guidelines has been endorsed by the Institute of Medicine. 7 In contrast, few AAP policy statements on well-child care are supported by direct evidence of net health benefit. 8 , 9

The rationale for the AAP's recommendation to routinely screen toddlers for autism spectrum disorders (ASDs) with ASD-specific screening tools is to advance the time of diagnosis and deliver early interventions. 10 Although a systematic review of 40 studies found that a policy of universal screening for ASD increased rates of diagnosis and referral, the effects of such policies on time of diagnosis or enrollment in services are unclear. 11 The entire body of evidence that intensive behavioral interventions improve language skills and cognitive or functional outcomes in children with ASD consists of a single randomized controlled trial and several prospective cohort studies of varying quality. 12 , 13

The AAP recommends measurement of blood pressure and cholesterol levels in children to identify modifiable risk factors for cardiovascular disease and to provide early interventions to reduce future risk. However, no studies have evaluated whether treating primary hypertension in persons younger than 18 years reduces adverse cardiovascular outcomes in adulthood. 14 , 15 Similarly, evidence is lacking that lowering cholesterol levels with lifestyle changes or medications improves cardiovascular outcomes, and long-term statin use is associated with rare but serious harms. 16 , 17

Time is a precious clinical resource. Clinicians who spend time delivering unproven or ineffective interventions at health maintenance visits risk “crowding out” effective services. For example, a national survey of family and internal medicine physicians regarding adult well-male examination practices found that physicians spent an average of five minutes discussing prostate-specific antigen screening (a service that the AAFP and the USPSTF recommend against because the harms outweigh the benefits 18 ), but one minute or less each on nutrition and smoking cessation counseling. 19 Similarly, family physicians have limited time at well-child visits and therefore should prioritize preventive services that have strong evidence of net benefit.

editor's note: Dr. Lin is associate deputy editor of AFP Online and chair of the Subcommittee on Clinical Practice Guidelines of the AAFP's Commission on the Health of the Public and Science. Because of Dr. Lin's dual roles, two other medical editors independently reviewed this editorial for publication.

Bazemore AW, Makaroff LA, Puffer JC, et al. Declining numbers of family physicians are caring for children. J Am Board Fam Med. 2012;25(2):139-140.

Riley M, Locke AB, Skye EP. Health maintenance in school-aged children: part II. Counseling recommendations. Am Fam Physician. 2011;83(6):689-694.

Simon GR, Baker C, Barden GA, et al. 2014 recommendations for pediatric preventive health care. Pediatrics. 2014;133(3):568-570.

American Academy of Pediatrics. Bright Futures. http://brightfutures.aap.org . Accessed August 20, 2014.

American Academy of Family Physicians. Summary of recommendations for clinical preventive services. July 2014. https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf . Accessed August 20, 2014.

Melnyk BM, Grossman DC, Chou R, et al. USPSTF perspective on evidence-based preventive recommendations for children. Pediatrics. 2012;130(2):e399-e407.

Graham R, Mancher M, Wolman DM, et al., eds. Clinical Practice Guidelines We Can Trust . Washington, DC: The National Academies Press; 2011.

Moyer VA, Butler M. Gaps in the evidence for well-child care: a challenge to our profession. Pediatrics. 2004;114(6):1511-1521.

Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. 2006;118(4):e964-e978.

Johnson CP, Myers SM American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.

Daniels AM, Halladay AK, Shih A, et al. Approaches to enhancing the early detection of autism spectrum disorders. J Am Acad Child Adolesc Psychiatry. 2014;53(2):141-152.

Warren Z, McPheeters ML, Sathe N, et al. A systematic review of early intensive intervention for autism spectrum disorders. Pediatrics. 2011;127(5):e1303-e1311.

Reichow B, Barton EE, Boyd BA, Hume K. Early intensive behavioral intervention (EBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2012;10:CD009260.

Chiolero A, Bovet P, Paradis G. Screening for elevated blood pressure in children and adolescents: a critical appraisal. JAMA Pediatr. 2013;167(3):266-273.

Thompson M, Dana T, Bougatsos C, Blazina I, Norris SL. Screening for hypertension in children and adolescents to prevent cardiovascular disease. Pediatrics. 2013;131(3):490-525.

Grossman DC, Moyer VA, Melnyk BM, Chou R, DeWitt TG U.S. Preventive Services Task Force. The anatomy of a U.S. Preventive Services Task Force recommendation: lipid screening for children and adolescents. Arch Pediatr Adolesc Med. 2011;165(3):205-210.

Psaty BM, Rivara FP. Universal screening and drug treatment of dyslipidemia in children and adolescents. JAMA. 2012;307(3):257-258.

Moyer VA U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Service Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134.

Pollack KI, Krause KM, Yarnall KS, Gradison M, Michener JL, Østbye T. Estimated time spent on preventive services by primary care physicians. BMC Health Serv Res. 2008;8:245.

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Autotext Dot Phrases for Cerner EHR

All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.

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• Sep 8, 2021

Well Child Check: 4 year old

SUBJECTIVE:

4 yo _ here for well child check. No parental concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Voiding/stooling: No concerns. + toilet trained (in the day at least).

- Sleeping: No concerns. Has regular bedtime routine.

- Dental: + brushes teeth. Sees the dentist regularly.

- Behavior: No concerns.

- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- Gross and fine motor: Hops/balances on one foot, can stack 8 blocks, brushes own teeth, dresses self (including buttons), uses scissors, walk up stairs with alternating feet, copies a cross.

- Cognitive: Knows first and last name, age, sex; draws person with at least 3 body parts; names at least 4 colors.

- Social/Emotional: Plays cooperatively, plays board/card games, plays make-believe.

- Communication: Strangers can understand speech, recognizes most letters. Speaks in 3-4 word sentences.

- No smokers in the home.

- No major social stressors at home.

- No safety concerns in the home.

- In preschool.

- No TB or lead risk factors.

IMMUNIZATIONS:

- Up to date.

- VITALS: _

- GEN: Normal general appearance. NAD.

- HEAD: NCAT.

- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.

- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.

- NECK: Supple, with no masses.

- CV: RRR, no m/r/g.

- LUNGS: CTAB, no w/r/c.

- ABD: Soft, NT/ND, NBS, no masses or organomegaly.

- GU: Normal _male genitalia. Testes descended bilaterally.

- SKIN: WWP. No skin rashes or abnormal lesions.

- MSK: Normal extremities & spine.

- NEURO: Normal muscle strength and tone. No focal deficits.

GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.

LABS/STUDIES:

- Urine dip normal.

- Hearing screen normal.

ASSESSMENT/PLAN:

* Healthy 4 yo child

- The family was given a children’s book today (per “Reach Out and Read” program).

- CBC ordered. No indication for a lipid panel or DM screening.

- MCHAT was done at 18 and 24 months of age.

- Follow up at 5 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Kinrix (DTaP #5 , IPV #4 ), MMR #2 , Varicella #2 , Influenza

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Safety: Street/car safety, strangers, gun safety, helmets and safety equipment.

- Booster seat required by law until 8 yrs old or 4’9”

- Food: Limiting juice and junk/fast food.

- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke

• Encounter Notes

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Court: 10k child sexual abuse images found on pastor’s devices, church computer

Church officers said he began locking his office any time he left, even to go to the bathroom..

GRANITE FALLS, N.C. (WBTV) - A Granite Falls pastor accused of having child sexual abuse materials has now been federally charged.

Ashley James Crouse was arrested November 3, 2023 following an investigation based off a tip from the National Center for Missing and Exploited Children.

The tip first came in April 2023 from the cloud storage service Dropbox, which reported one of its users possessed child pornography.

The name, email address and IP addresses used were traced back to Crouse.

Deputies with the Caldwell County Sheriff’s Office and investigators with the North Carolina State Bureau of Investigation searched Crouse’s home and New Vision Baptist Fellowship on Nov. 3.

[ Deputies: Pastor arrested on child sex charges in Caldwell County ]

During that time, Crouse was interviewed by investigators and, according to law enforcement, admitted to knowingly obtaining and using child pornography.

Crouse also admitted to watching it on his church computer while multi-tasking and completing church business, according to federal documents.

Investigators reported they found more than 10,000 images depicting child sexual abuse across devices found in Crouse’s home and church office – including his church computer.

According to police records, the materials depicted children younger than 10 years old engaged in sexual acts.

Two church officers allegedly told investigators that Crouse had started to lock his office, even if he was going to the bathroom. According to federal documents, they also said they had not seen the inside of his office for months prior to Nov. 3.

Crouse was initially charged with four counts of second-degree sexual exploitation of a minor. An additional four counts of third-degree sexual exploitation of a minor were later added.

Now, he is also facing a federal charge of receipt of child pornography.

Copyright 2024 WBTV. All rights reserved.

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Drunk driver in Michigan birthday party crash that killed young siblings, 4 and 8, charged with murder

An intoxicated driver was charged with murder after crashing into a Michigan business where a child's birthday party was being held and killing two young siblings, authorities announced Tuesday.

Marshella Chidester, 66, hit a building at Swan Boat Club in Berlin Charter Township around 3 p.m. on Saturday. It came to a stop 25 feet inside where the party was taking place, Monroe County Sheriff Troy Goodnough told reporters Saturday.

In an arraignment hearing Tuesday, Chidester was charged with two counts of second-degree murder, two counts of operating under the influence of alcohol causing death and four counts of operating under the influence of alcohol causing serious injury. Her bond was set at $1.5 million. If convicted, Chidester could be sentenced to up to life in prison.

Zayn Phillips, 4, and his sister, Alanah Phillips, 8, were declared dead at the scene, Goodnough said in an update Monday. The sheriff's office previously reported that Zayn was 5-years-old.

A third sibling survived with “severe injuries," according to Andrew Brodie, the superintendent of Flat Rock Community Schools, an area public school district.

At the arraignment, Bill Colovos, an attorney for Chidester, said she has a history of epileptic seizures in her legs and lost control of the car when she crashed. He also said that his client only had one glass of wine four hours before the crash, according to a search warrant executed at the bar where she allegedly was.

"This is not a monster," Colovos said about his client, adding that she doesn't have a criminal history. "It’s horrible what happened, absolutely horrible. I have two children. It's absolutely horrible. But some things we don’t have control over."

Chidester was seen in court with a cast on her right arm, wearing a striped white and black prison uniform.

Monroe County Prosecuting Attorney Jeffery A. Yorkey refuted the claim that Chidester had a seizure during the crash and said that "her blood alcohol level was significantly over the legal limit." He didn't mention what her blood alcohol level was.

"There is no indication, whatsoever, in any of the evidence that we have uncovered in this case, that the defendant suffered from a seizure at the time of this incident," Yorkey said during the hearing.

"She indicated herself that she had some seizure issues and she was on some medication, and that she wasn't supposed to be drinking, but admitted that she had been drinking that day," Yorkey said.

A woman who identified herself as the grandmother of Zayn and Alanah spoke at the arraignment, accusing Chidester of drinking and driving.

"She chose to drink and drive and she took my grandbabies from us," the woman said.

A woman who identified herself as the aunt of the two children said she was at the scene of the crash, and saw her niece and nephew in their final moments.

"They walked into that birthday party having a fun time," she said. "They were sitting at that table, eating, and this woman crashed her car through this building, destroying all of our lives. Not just my family, everyone else that was in that building."

She says her other nephew and her sister, the children's mother, were hurt in the crash and are still fighting for their lives.

"I had to be the one to tell my sister her babies were gone when they removed her ventilator yesterday," the woman said. "She said 'How am I supposed to live without my babies?'"

"No one should ever have to go to a birthday party thinking that they’re gonna die," she said tearfully.

Zayn's birthday was coming up next month, according to Monroe County Undersheriff Joe Hammond.

"We were supposed to be planning a birthday party for Zayn, not a funeral," the child's aunt said.

Approximately 13 others were injured in the crash, Goodnough said on Saturday. Nine of those people, who range in age from 11 to 66-years-old, were hospitalized, according to the Monroe County Sheriff’s Office.

Five remain in critical condition, including an 11-year-old boy, a 14-year-old boy, a 16-year-old girl, an 18-year-old woman and a 31-year-old woman.

The four other victims, who range in age from 57 to 70, had minor injuries. A 42-year-old man also received treatment on his own for minor injuries.

Chidester's next court appearance is scheduled for April 30.

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Biden meets 4-year-old Abigail Edan, an American who was held hostage by Hamas

FILE - People walk past an image of 4-year-old Abigail Edan, a hostage held by Hamas, projected onto a building in Tel Aviv, Nov 26, 2023. Edan’s parents were both killed by Hamas militants in the same attack in which she was kidnapped, a cross-border assault Oct. 7 that prompted Israel to declare war on Hamas. President Joe Biden has met at the White House with Abigail Edan. (AP Photo/Ariel Schalit, File)

President Joe Biden speaks to the North America’s Building Trade Union National Legislative Conference, Wednesday, April 24, 2024, in Washington. (AP Photo/Evan Vucci)

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WASHINGTON (AP) — President Joe Biden met Wednesday with Abigail Edan, the 4-year-old American girl who was held hostage in Gaza for several weeks at the start of the war.

White House national security adviser Jake Sullivan said the White House meeting with Abigail and her family was “a reminder of the work still to do” to win the release of dozens of people who were taken captive by Hamas in an Oct. 7 attack on Israel and are still believed to be in captivity in Gaza.

Abigail, who has dual Israeli-U.S. citizenship, was taken hostage after her parents were killed in the attack and was released nearly seven weeks later. She was the first U.S. hostage freed by Hamas as part of a deal with Israel to exchange hostages for Palestinian prisoners early in the war. Abigail turned four during her time in captivity.

“It was also a reminder in getting to see her that there are still Americans and others being held hostage by Hamas,” said Sullivan, who attended Biden’s meeting with the girl and her family. “And we’re working day in, day out to ensure all of them also are able to get safely home to their loved ones. ”

AP AUDIO: Biden meets 4-year-old Abigail Edan, an American who was held hostage by Hamas.

At a news conference, White House national security adviser Jake Sullivan says the president hosted 4-year-old Abigail Edan and her family. ((Edan is pronounced eh-DAHN’)

Israel says the militants are still holding around 100 hostages and the remains of more than 30 others.

Biden spoke to the girl soon after her release in November. Thursday’s meeting was one of mixed emotions for the president.

Sullivan noted that Abigail and her two siblings were “still living with the tragedy and the trauma” of their parents being killed on Oct. 7.

“Abigail, of course, is living with the trauma of being held captive for many weeks,” he added. “But this was a moment of joy as well, because she was able to be returned safely to her family. ”

Biden’s meeting with Abigail came as Hamas on Wednesday released a recorded video of an Israeli American still being held by the group.

The video was the first sign of life of Hersh Goldberg-Polin since Hamas’ Oct. 7 attack on southern Israel. It was not clear when the video was taken.

Goldberg-Polin, 23, was at the Tribe of Nova music festival when Hamas launched its attack from nearby Gaza. In the video, Goldberg-Polin is missing part of his left arm.

Witnesses said he lost it when attackers tossed grenades into a shelter where people had taken refuge. He tied a tourniquet around it before being bundled into the truck.

Sullivan said U.S. law enforcement officials are assessing the video but declined further comment.