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1-Month Well-Child

Presents for a 1-month well-child check-up
Accompanied by: 


Birth length:  cm
Birth weight:  g
Birth head circumference:  cm
Discharge weight:  g

Past medical history:  
Medications:  
Allergies:  
Family history:  
Known risk factors:  

Current symptoms or caregiver concerns:  

NUTRITION:
Breastfeeding: ,  feeds daily
Vitamin D 400 IU/day (if breastfeeding): 
Formula feeding/Preparation (450-750 ml (15-25 oz)/kg/day):   daily, type: 
Regurgitation: 
Choking during feeding: 
Iron supplement (if prematurity): 
Stool pattern and urine output:  

EDUCATION AND ADVICE:
Sleep: total  hrs per day
Sleep habits:  
Living with: , 
Parenting/bonding: 
Family conflict/stress: 
Parental fatigue/postpartum depression: 
Difficulty making ends meet or food insecurity: 
High-risk infants/assess home visit need: 
Second hand smoke exposure: 
Complementary/alternative medicine: 
Counseling:
- Falls (stairs, change table)
- Carbon monoxide/smoke detectors
- Choking/safe toys
- Poison prevention (poison control center)
- Car seat facing back
- Burn prevention
- Hot water <49°C/bath safety
- Safe sleep (room sharing, avoid bed sharing, crib safety)
- Limit sun exposure
- Supervised tummy time while awake
- Water not required if exclusive breastfeeding
- No OTC cough/cold medicine
- Temperature control and overdressing
- Fever advice

DEVELOPMENT:
Focuses gaze: 
Startles to loud noise: 
Calm when comforted: 
Sucks well on nipple: 
Pulls his head off the bed surface on belly: 

EXAM:
General appearance: 
Vital signs: , BP , HR , RR , SpO2  %, Temp °
Measurements: length:  cm -  perc, weight:  kg -  perc, head circ:  cm -  perc
Head: fontanelles , 
Eyes: -R: , -L: , , , red reflex , corneal light reflex , fix and follow test 
Ears: -R: , -L: 
Nose: , , discharge , 
Throat: 
Neck: 
Heart: , 
Lungs: , 
Abdomen: , , , 
Genital: , testicles , penis 
Extremities: , , cap refill , Barlow , Ortolani 
Skin: 
Musculoskeletal: joints  , 
Neurologic: cranial nerves , global motricity , muscle tone , gait 
Mental status: , , reactive to 
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive: 

ASSESSMENT:
 
DDx: 

PLAN:
* Varies based on local guidelines
- Hearing screening if not done at birth
- Vision screening if at risk
- Hemoglobinopathy screen (if at risk)
- Caregiver questions answered
- Iron supplementation if premature
- Vitamin D supplementation if breastfeeding or premature
- Immunizations: if HBsAg-positive parent/sibling Hep B vaccine #2
- Referral to resources and support for parents if needed
- Follow-up in