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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)

Height :

Weight :

Head circumference (if prior abnormal) :

BMI :



PARENT/CAREGIVER CONCERNS :





NUTRITION

‍Breastfeeding/Vitamin D 400 IU/day

‍Skim, 1% or 2% milk (~ 500 mLs(16 oz)/day)

‍Avoid juice and food/beverages high in sugar or salt

‍Gradual transition to lower fat diet

‍Canada’s Food Guide

‍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 (child/booster)

‍Bike helmets

‍Poisons; PCC

‍Firearm safety

‍Water safety

‍Carbon monoxide/smoke detectors/ Burns/Matches

‍Falls (stairs, unstable furniture/TV, trampolines)

‍No pacifiers



Behaviour

‍Parent/child interaction

‍Discipline/Parenting skills programs

‍High-risk children

‍Parental fatigue/Depression

‍Family conflict/Stress

‍Siblings



Family

‍Healthy sleep habits

‍Family healthy active living/Sedentary behaviour/Screen time

‍Inquire re: difficulty making ends meet or food insecurity

‍Encourage reading

‍Assess child care/Preschool needs/School readiness

‍Socializing opportunities



Environmental Health

‍2nd hand smoke/E-cigs/Cannabis

‍Pesticide exposure

‍Sun exposure/Sunscreens/Insect repellent



Others

‍Dental cleaning/Fluoride/Dentist

‍Complementary/alternative medicine

‍No OTC cough/cold medicine

‍Toilet learning



DEVELOPMENT

‍Combines 2 or more words

‍Understands 1 and 2 step directions

‍Walks backward 2 steps without support

‍Tries to run

‍Puts objects into small container

‍Uses toys for pretend play (e.g. give doll a drink)

‍Continues to develop new skills

‍No parent/caregiver concerns



PHYSICAL EXAMINATION

‍Eyes (red reflex)/Visual acuity

‍Corneal light reflex/Cover-uncover test and  inquiry

‍Hearing inquiry

‍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