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12-Month Well-Child

Presents for a 12-month well-child check-up
Accompanied by: 


Past medical history:  
Medications:  
Allergies:  
Family history:  
Known risk factors:  

Current symptoms or caregiver concerns:
 

NUTRITION:
Breastfeeding: ,  feeds daily
Homogenized milk (500–750 ml or 16-24 oz):   daily
Vitamin D 400 IU/day: 
Vegeterian diet: 
Appetite: 
Counseling:
- Eat family foods
- Eat variety of textures
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- Promote open cup instead of bottle
- Avoid bottles in bed

EDUCATION AND ADVICE:
Sleep (11-14 hrs per day): total  hrs per day
Sleep habits: , , , 
Daycare: , 
Living with: , 
Parenting/bonding: 
Family conflict/stress: 
Second hand smoke exposure: 
Complementary/alternative medicine: 
Counseling:
- Encourage reading
- Avoid screens
- Promote physical activity
- Poison prevention (poison control center)
- Car seat facing back
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Safe sleep (avoid bed sharing, crib safety)
- Limit sun exposure / sunscreens
- Dental cleaning
- Fever advice

DEVELOPMENT:
Responds to own name: 
Understands simple requests (e.g. Where is the ball?): 
Makes consonant/vowel combinations: 
Says 3 or more words: 
Crawls or pulls to stand: 
Shows distress when separated: 

EXAM:
General appearance: 
Vital signs: , BP , HR , RR , SpO2  %, Temp °
Measurements: length:  cm -  perc, weight:  kg -  perc, head circ:  cm -  perc
Head: fontanelles , 
Eyes: -R: , -L: , , , red reflex , corneal light reflex , fix and follow test 
Ears: -R: , -L: 
Nose: , , discharge , 
Throat: 
Neck: 
Heart: , 
Lungs: , 
Abdomen: , , , 
Genital: , testicles , penis 
Extremities: , , cap refill , Barlow , Ortolani 
Skin: 
Musculoskeletal: joints  , 
Neurologic: cranial nerves , global motricity , muscle tone , gait 
Mental status: , , reactive to 
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive: 

ASSESSMENT:
 
DDx: 

PLAN:
- Blood work:  if at risk of anemia,  if at risk
- Hearing screening
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods
- Vitamin D supplementation
- Immunizations: , , , , , , 
- Referral to dentist
- Follow-up in