The Rourke Baby Record is Canada’s evidence-based guide to well-baby and well-child visits from birth to age 5. This visit note covers the same areas, from growth and feeding to milestones and vaccines. Copy the free template, see a 2-month visit in British Columbia and an enhanced 18-month visit in Ontario, and find the official Rourke forms.
For clinicians in Canada.
Blank rourke Baby Record visit note template
FreeROURKE BABY RECORD VISIT NOTE, BIRTH TO 5 YEARS Child: [Name, sex] Date of birth and age: [Date; age in weeks, months, or years] Rourke visit: [Within 1 week, 2 weeks, 1 month, 2, 4, 6, 9, 12 to 13, 15, or 18 months, or 2, 3, 4, or 5 years] Gestational age at birth: [Weeks; corrected age if born before 37 weeks] Came with: [Parent or caregiver, and anyone else present] Province or territory: [Sets the vaccine schedule and the local programs] Clinician: [Name, credentials] BACKGROUND Birth and past problems: [Pregnancy and birth, birth weight, NICU stay, illnesses so far] Family history and risks: [Conditions in the family; housing, money, or food worries] Since the last visit: [Illnesses, emergency visits, medicines, new diagnoses] Parent concerns: [What the family wants to talk about, in their words] GROWTH ON THE WHO GROWTH CHARTS FOR CANADA Weight: [kg and percentile; change since the last visit] Length or height: [cm and percentile; measured lying down until age 2] Head circumference: [cm and percentile; until age 2] Weight-for-length or BMI: [Weight-for-length until age 2, then BMI-for-age, with percentile] Pattern: [Tracking a channel, or crossing two major percentile lines] FEEDING AND NUTRITION Milk: [Breastfeeding, formula in mL a day, or 3.25% cow's milk in mL a day; bottle or open cup] Vitamin D: [400 IU a day for a breastfed child, given or not] Foods: [When solids started, iron-rich foods a day, textures, self-feeding, family meals] Drinks and diet: [Juice, sweet drinks, water; vegetarian or vegan diet; picky eating] Diapers and stools: [Wet diapers and stools a day; pale or white stools in the first weeks] ADVICE GIVEN Safety: [Car seat stage and fit, safe sleep, falls, burns, poisons, choking, water, firearms] Family and behaviour: [Sleep, crying or tantrums, parent fatigue and mood with tool and score, family stress, reading and singing together] Environment: [Smoke, vaping, and cannabis exposure; sun and insect repellent; lead risk] Other topics: [Tummy time, teeth and fluoride, screens and active play, fever advice, toilet learning] DEVELOPMENT Milestones for this visit: [Gross motor, fine motor, communication, thinking, and social-emotional skills, seen or reported] Not yet met or lost: [Each milestone not met, any skill lost, or none] Screening tool: [Tool and result, such as the Looksee Checklist or the M-CHAT-R/F; or none used] PHYSICAL EXAMINATION General: [How the child looks, moves, and interacts] Findings for age: [Fontanelles, skin and any unexplained bruises, eyes with red reflex and cover-uncover test, ears and hearing, mouth and teeth, neck, heart, lungs, abdomen, genitals, hips, spine, tone] INVESTIGATIONS AND SCREENING Results and tests: [Newborn blood spot and hearing results; hemoglobin and ferritin if at risk; blood lead if at risk; vision and blood pressure from age 3] IMMUNIZATIONS Due on the provincial schedule: [Vaccines due at this age] Given today: [Vaccine, site, and lot; or deferred or declined, with the discussion] Comfort measures: [Breastfeeding, holding, sweet solution, or topical anesthetic] Next due: [Vaccines and the age they are due] PROBLEMS AND PLANS Assessment: [Healthy child growing and developing well, or each concern] Plan: [Each concern with its next step and follow-up date] Referrals: [Speech-language, audiology, dentist, dietitian, physiotherapy, parenting or early years programs; or none] Next visit: [Next Rourke visit age, or a sooner follow-up] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice in British Columbia, with both parents
9-week-old girl, born at 39 weeks by vaginal birth; birth weight 3.25 kg; no NICU stay. Her midwife transferred her care to the practice at 6 weeks. Newborn blood spot screen normal; passed the newborn hearing screen in both ears. No illnesses or medicines. No family history of hip dysplasia or hearing loss. Parents’ concerns: a flat spot on the back of her head, and whether she can sleep in their bed so her mother gets more rest.
Weight 4.96 kg, 40th percentile on the WHO Growth Charts for Canada; birth weight was near the 50th, so she is tracking. Gaining about 27 g a day since birth. Length 57.0 cm, 50th percentile. Head circumference 38.0 cm, 40th percentile. Weight-for-length near the 50th percentile.
Exclusively breastfed, 8 to 10 feeds in 24 hours, no nipple pain. 6 to 8 heavy wet diapers and 3 to 4 yellow stools a day; no pale stools. Vitamin D 400 IU drops daily since the first week. Her mother takes a daily multivitamin with vitamin D.
Safe sleep: twice this week her mother fell asleep with her on the sofa during the 3 a.m. feed. Explained that a sofa or armchair is the most dangerous place to fall asleep with a baby, and that bed sharing raises the risk of sudden infant death. Plan agreed: feed in bed with the bassinet beside it, and lay her on her back in the bassinet after each feed. Car seat: rear-facing infant seat, harness snug, chest clip at armpit level, no bulky snowsuit under the straps. Mother tired but coping; father on parental leave until January; EPDS 6, with 0 on the self-harm question. Tummy time while awake several times a day. A temperature of 38.0 °C or higher by rectal thermometer at this age means being seen urgently. No cough and cold medicines. Reading and singing to her every day.
Lifts her head during tummy time; follows a face from side to side; startles and turns toward her parents’ voices; smiling back at them since 6 weeks; settles when held and rocked. All milestones for the visit met. No parent concerns about development.
Alert, content, good colour. No bruises, eye hemorrhages, or mouth injuries. Anterior fontanelle soft and flat. Mild flattening on the right side of the back of the head, with the right ear slightly forward: the pattern of positional flattening. Prefers to look to the right, but turns fully to both sides; no neck tightness or mass. Red reflex present in both eyes; fixes and follows. Heart regular, no murmur; femoral pulses normal. Lungs clear. Abdomen soft; umbilicus healed. Hips: Ortolani and Barlow negative, full and equal abduction. Normal female genitalia. Tone normal. No jaundice.
Due at 2 months on the BC schedule: DTaP-HB-IPV-Hib, Pneu-C-20, Men-C-C, and rotavirus. All given today after the parents’ questions were answered: rotavirus by mouth first, then three injections into the thighs while she breastfed. Observed for 15 minutes; no reaction. Acetaminophen by weight afterward only if she is feverish or fussy, not before. Next doses at the 4-month visit.
Healthy 2-month-old, growing and developing well. 1. Mild positional flattening, no torticollis: supervised tummy time several times a day, alternate which end of the bassinet her head is at each night, and more upright carrying; recheck at 4 months, with a physiotherapy referral if it worsens or a neck preference appears. 2. Sofa sleeping: safe sleep plan agreed, as above. 3. Mother’s fatigue: father to take the baby after the early-morning feed so she can sleep; repeat the EPDS at 4 months, sooner if her mood drops. Next Rourke visit at 4 months.
Family health team in Ontario, enhanced 18-month well-baby visit with his mother
18-month-old boy, born at 38 weeks; no NICU stay; passed the newborn hearing screen. Two ear infections this year, the last in August; no medicines. Lives with his parents and his 5-year-old sister; in home daycare 3 days a week. His mother completed the Looksee Checklist in the waiting room. Concerns: “He only says a few words, and his sister was talking much earlier.” She also asks about picky eating and when to turn his car seat around.
Weight 11.6 kg, 70th percentile. Length 82.5 cm, 55th percentile. Head circumference 47.6 cm, 55th percentile. Weight-for-length 70th percentile on the WHO Growth Charts for Canada. All in the same channels since 9 months.
Stopped breastfeeding at 12 months; vitamin D drops stopped then. Whole 3.25% milk about 900 mL a day, mostly by bottle, including a bottle to fall asleep and one at 3 a.m. Eats pasta, bread, crackers, yogurt, cheese, and fruit; refuses meat and most vegetables. Iron-fortified infant cereal stopped at 12 months, so iron-rich foods are rare. Feeds himself with fingers and a spoon; family dinners most nights. No juice.
Looksee Checklist, 18 months: two language items answered no; all others yes. Walks well and squats to pick up toys; stacks 3 blocks; scribbles. Says 6 words: mama, dada, ball, up, dog, and “nana” for banana. Understands well: follows one-step directions without gestures and points to his nose, eyes, and belly when asked. Points out a dog through the window and looks back at his mother; turns to his name; brings books to be read; waves and plays near other children at daycare. No lost skills. M-CHAT-R/F, done because of the language concern: total score 1, low risk.
Car seat: still rear-facing in a convertible seat, and his feet touch the seat back. Explained that bent legs are safe and that rear-facing protects his head and neck best, so stay rear-facing until he reaches the seat’s rear-facing weight or height limit. Screens: cartoons on a tablet about 1 hour a day while dinner is made; advised no screen time before age 2 apart from video calls, and a basket of kitchen toys instead. Picky eating: parents choose what is served and when; he chooses whether and how much to eat; offer new foods beside ones he likes, many times. Medicines in a locked box; no cannabis at home. Shared books every night; encouraged naming what he looks at and pausing for him to try a word. No money or food worries. Given the Play and Learn website and the local EarlyON centre for play groups.
Busy, curious, and sociable; points and babbles through the visit. Anterior fontanelle closed. Red reflex present in both eyes; corneal light reflex symmetric; cover-uncover test normal. Ear drums normal, no fluid. 12 teeth; chalky white bands along the gum line of the upper front teeth, no cavities seen. Tonsils small; no snoring. Heart, lungs, and abdomen normal. Walks steadily.
At risk of iron deficiency: more than 500 mL of milk a day, a bottle past 15 months, and few iron-rich foods. CBC and ferritin ordered. No lead risk factors; the family’s house was built in 2004.
Due at 18 months on the Ontario schedule: DTaP-IPV-Hib, given today in the thigh while his mother held him. Varicella was given at 15 months. Influenza vaccine: 1 dose given today, as he had 2 doses last season. Next routine vaccines at 4 years: Tdap-IPV and MMRV.
1. Expressive language delay: 6 words at 18 months, with good understanding, pointing, and social skills; M-CHAT-R/F low risk. With his mother’s consent, referral to the local Preschool Speech and Language program, and to audiology for a full hearing test because of the ear infections. Repeat the M-CHAT-R/F at 24 months. 2. Iron deficiency risk and picky eating: milk down to 500 mL a day from an open cup with meals; night bottle stopped first, then the bedtime bottle; an iron-rich food at 2 meals a day, such as beans, lentils, eggs, tofu, meat, or iron-fortified cereal. The clinic will call with the CBC and ferritin, and start iron if ferritin is low. 3. Early tooth decay: brush twice a day with a rice-grain smear of fluoride toothpaste, with no milk after bedtime brushing; first dental visit booked this month. 4. Car seat stays rear-facing. Next Rourke visit at 2 years, sooner with the referral results or if he loses any words.
The Rourke Baby Record is free to download from rourkebabyrecord.ca, with a French site. The current forms are the 2024 edition, revised May 18, 2024, and copyright Drs. Leslie Rourke, Denis Leduc and James Rourke. Putting the form into an EMR needs a licence from the authors. The template on this page is Vero’s own visit note that covers the same areas; it doesn’t copy the form.
Weigh and measure at every visit and plot on the WHO Growth Charts for Canada, the charts the Rourke record uses. One point says little; the line over several visits says a lot.
Avoid: A percentile with no trend. A baby who drops from the 75th to the 25th needs a feeding history, even though the 25th looks normal on its own.
What the child drinks and eats, in amounts, so your advice can be specific.
Avoid: “Eats well.” Write the millilitres of milk a day and how often iron-rich foods appear; that is where iron deficiency starts.
The safety, family, and health topics for this age. Record the ones you covered, and what the family plans to do.
Avoid: Every topic ticked at every visit. Pick what this family needs today, and write what they said they would do.
The skills set for the visit age, asked about and watched for. The Rourke milestones sit after the age most children reach them, so one that is missing, a lost skill, or a parent’s worry each calls for a closer look.
Avoid: Waiting for the next visit after a missed milestone. Book the hearing test, the referral, or a short-interval recheck now.
An exam that fits the age, with the checks that find problems early.
Avoid: Moving past a bruise on a baby who can’t yet roll or crawl. It needs an explanation that fits and, if none does, a work-up for abuse or a bleeding problem.
Vaccines follow the child’s provincial or territorial schedule, which differs from one province to the next.
Avoid: Copying the vaccine list from an old note. Ontario gives DTaP-IPV-Hib at 2 months; British Columbia gives DTaP-HB-IPV-Hib, Pneu-C-20, and a meningococcal C vaccine. Check the current schedule for the child’s province.
The Rourke milestones are set after the age most children reach them. One that is missing, a skill that is lost, or a parent’s worry each merits a closer look: a hearing test, a referral, or a recheck with a date.
For a baby born before 37 weeks, the Rourke record corrects age for development until 2, and for growth until about 24 to 36 months. A 9-month-old born at 30 weeks is plotted and judged as a 7-month-old.
More than 500 mL of milk a day, or a bottle past 15 months, puts a toddler at risk of iron deficiency. Write the volume, aim for 500 to 600 mL a day at most from a cup, and ask how often iron-rich foods appear.
Keep a child in each car seat stage until the seat’s weight or height limit is reached, not the youngest age the law allows. Feet touching the seat back is not a reason to turn a toddler forward.
A recheck with no date tends not to happen. Put the referral, the follow-up date, and who calls with the results into the plan.
Vero Scribe drafts the visit note in your template from the conversation, with the family’s consent, or from your dictation. You review and edit every section, then copy it into your EMR or export it to Word or PDF. Vero works in 60+ languages.
An evidence-based guide to health supervision from birth to 5 years, widely used for well-baby care across Canada. It began in 1979 as a flow chart in the Goderich, Ontario, family practice of Drs. James and Leslie Rourke and was first published in 1985. The 2024 edition carries the names of Drs. Leslie Rourke, Denis Leduc and James Rourke, is endorsed by the Canadian Paediatric Society, the College of Family Physicians of Canada, and Dietitians of Canada, and is funded by the Government of Ontario.
From rourkebabyrecord.ca/downloads, free of charge. There is a national version and an Ontario version, each in three print layouts and as a fillable PDF, plus notes pages with the evidence behind each item. Putting the form into an EMR needs a licence from the authors. The template on this page is Vero’s own visit note that covers the same areas, for your EMR or for Vero.
Within the first week, 2 weeks, 1 month, 2, 4, 6, 9, 12 to 13, 15, and 18 months, then 2, 3, 4, and 5 years. Many fall on the ages of routine vaccines, so the checkup and the shots happen at one visit.
An Ontario visit at 18 months with extra time for development. The parent completes a checklist such as the Looksee Checklist, and the clinician reviews it alongside the Rourke 18-month guide, gives the 18-month vaccine, and connects the family to supports such as EarlyON centres, or to speech-language and other services when needed. The Ontario version of the Rourke record includes it.
Yes. Copy it, or download it as a Word or text file. No account needed.
The sick-visit SOAP note for children, with caregiver history, hydration, and weight-based doses.
Growth, development, screening, vaccines, and safety guidance, with 12-month and 5-year examples.
Milestones by domain, ASQ-3 and M-CHAT-R/F results, corrected age, and the refer-or-rescreen decision.
The diagnostic report after an autism assessment: history, ADOS-2 and other results, DSM-5-TR criteria, support levels, and recommendations.
The preventive visit from 6 to 17, organized like the Greig Health Record, with an Ontario and a BC example.
Well-baby and sick-visit notes from conversations with children and families.
The codes used most often in pediatrics.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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