WELL-CHILD VISIT

Patient: [Name]
Date of birth and age: [Date; age in months or years]
Date of visit: [Date]
Visit: [Scheduled well-child visit, such as 12-month or 5-year]
Accompanied by: [Caregiver and relationship to the child]
Clinician: [Name, credentials]

INTERVAL HISTORY
Since the last visit: [Illnesses, emergency visits, hospital stays, new diagnoses, medication changes]
Caregiver concerns: [Questions and worries raised today]
Family and social changes: [New sibling, move, childcare or school change, stressors, supports]

GROWTH
Weight: [kg and lb, percentile]
Length or height: [cm and in, percentile; length lying down under age 2]
Head circumference: [cm and in, percentile; to age 2]
Weight-for-length or BMI: [Weight-for-length percentile under age 2; BMI and BMI percentile from age 2]
Trend: [Following the curve, or crossing percentile lines]
Vital signs: [Temperature, HR, RR; BP from age 3, or earlier if at risk]

NUTRITION AND DAILY HABITS
Feeding: [Breast milk, formula, or milk with amount per day; solids, textures, cup use, self-feeding]
Diet: [Fruits and vegetables, juice and sweet drinks, water, picky eating]
Supplements: [Vitamin D, iron, fluoride, or none]
Sleep: [Hours and naps, bedtime routine, night waking, sleep position and place for infants, snoring]
Elimination: [Stool pattern, constipation, voiding, toilet training, bedwetting]
Activity and screens: [Active play, daily screen time]

DEVELOPMENT
Screening tool: [Standardized tool and age form used, and the result; or not due at this visit]
Gross motor: [Milestones seen or reported]
Fine motor: [Milestones seen or reported]
Language: [Words or sentences, understanding, speech clarity]
Social and emotional: [Play, interaction, behavior]
Autism screening: [Tool and result, if due at this age per local schedule]
School or childcare: [Setting, readiness, progress, teacher concerns]

SCREENING
Vision: [Method and result, such as red reflex, instrument-based screening, or acuity in each eye]
Hearing: [Newborn hearing result, or method and result today]
Oral health: [Teeth, brushing with fluoride toothpaste, dental visits, fluoride varnish]
Other screening: [Hemoglobin, lead exposure risk, or other tests due at this age per local practice]
Caregiver and family: [Caregiver mood, family stress, food security]

IMMUNIZATIONS
Status: [Up to date per local schedule, or doses due]
Given today: [Vaccines given; or declined, with the discussion recorded]
Next due: [Vaccines and the age they are due]

SAFETY AND ANTICIPATORY GUIDANCE
Topics discussed: [Car seat or booster, water, fire, falls, poisons and medicines, safe storage, sun, helmets]
Age-specific guidance: [What to expect before the next visit]

PHYSICAL EXAMINATION
General: [Appearance, interaction with caregiver and clinician]
Findings: [Skin, head and fontanelle, eyes, ears, mouth and teeth, neck, heart, lungs, abdomen, genitalia, hips and spine, neurological and tone]

ASSESSMENT AND PLAN
Assessment: [Healthy child with normal growth and development, or the concerns found]
Concerns: [Each concern, with its plan]
Referrals: [Early intervention, audiology, eye care, dental, or other services]
Forms: [School, childcare, or activity forms completed]
Next visit: [Age of the next well-child visit, and reasons to come sooner]

Signed: [Clinician name, credentials, date and time]