ROURKE 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]