Presents for a 12-month well-child check-up
Accompanied by:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Homogenized milk (500–750 ml or 16-24 oz): daily
Vitamin D 400 IU/day:
Vegeterian diet:
Appetite:
Counseling:
- Eat family foods
- Eat variety of textures
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- Promote open cup instead of bottle
- Avoid bottles in bed
EDUCATION AND ADVICE:
Sleep (11-14 hrs per day): total hrs per day
Sleep habits: , , ,
Daycare: ,
Living with: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Complementary/alternative medicine:
Counseling:
- Encourage reading
- Avoid screens
- Promote physical activity
- Poison prevention (poison control center)
- Car seat facing back
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Safe sleep (avoid bed sharing, crib safety)
- Limit sun exposure / sunscreens
- Dental cleaning
- Fever advice
DEVELOPMENT:
Responds to own name:
Understands simple requests (e.g. Where is the ball?):
Makes consonant/vowel combinations:
Says 3 or more words:
Crawls or pulls to stand:
Shows distress when separated:
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:
- Blood work: if at risk of anemia, if at risk
- Hearing screening
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods
- Vitamin D supplementation
- Immunizations: , , , , , ,
- Referral to dentist
- Follow-up in