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Gestational Age: 

Birth Length: ‍ cm

Birth Weight: ‍ g

Birth Head Circumference:‍ cm



Past problems/Risk factors :

Family history :



GROWTH (Correct age until 24-36 months if < 37 weeks gestation)

Lenght :

Weight :

Head circ. :



PARENT/CAREGIVER CONCERNS :





NUTRITION

‍Breastfeeding/Vitamin D 400 IU/day

‍Homogenized milk (500–750 mL (16–24 oz)/day)

‍Avoid juice and food/beverages high in sugar or salt

‍No bottles

‍Independent/self-feeding

‍Inquire re: vegetarian diets



EDUCATION AND ADVICE (repeat discussion of items is based on perceived risk or need)

Injury Prevention

‍Motorized vehicle safety/Car seat

‍Safe sleep (position, room sharing, avoid bed sharing, crib safety)

‍Poisons; PCC

‍Bath safety/Burns

‍Choking/Safe toys

‍Wean from pacifier

‍Electric plugs/cords

‍Falls (stairs, change table, unstable furniture/TV)



Behaviour

‍Parent/child interaction

‍Healthy sleep habits

‍Discipline/Parenting skills programs



Family

‍High-risk children

‍Encourage reading

‍Parental fatigue/Stress/Depression

‍Inquire re: difficulty making ends meet or food insecurity

‍Family healthy active living/Sedentary behaviour/Screen time

‍Socializing/Peer play opportunities



Environmental Health

‍2nd hand smoke/E-cigs/Cannabis

‍Pesticide exposure

‍Sun exposure/Sunscreens/Insect repellent



Other

‍Dental care/Dentist

‍Toilet learning



DEVELOPMENT

Social/Emotional

‍Interested in other children

‍Usually easy to soothe

‍Child’s behaviour is usually manageable

‍Comes for comfort when distressed



Communication Skills

‍Points to several different body parts

‍Tries to get your attention to show you something

‍Turns/responds when name is called

‍Points to what he/she wants

‍Looks for toy when asked or pointed in direction

‍Imitates speech sounds and gestures

‍Says 15 or more words (words do not have to be clear)

‍Produces 4 consonants (e.g. B D G H N W)



Motor Skills

‍Feeds self with spoon with little spilling

‍Walks alone



Adaptive Skills

‍Removes hat/socks without help

‍No parent/caregiver concerns





PHYSICAL EXAMINATION

‍Anterior fontanelle

‍Eyes (red reflex)

‍Corneal light reflex/Cover-uncover test and inquiry

‍Hearing inquiry/screening

‍Teeth/Caries risk

‍Tonsil size/Sleep-disordered breathing

‍Heart/Lungs/Abdomen



PROBLEMS AND PLANS/CURRENT AND NEW REFERRALS

(e.g. medical specialist, dietitian, speech, audiology, PT, OT, eyes, dental, social determinants resources) :





INVESTIGATIONS/SCREENING AND IMMUNIZATION (discuss immunization benefits and pain reduction strategies)

‍Anemia screening (If at risk)

‍Blood lead if at risk