Well Child Visit Form -10-12 Months
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1Well Child Visit: 10-12 Months
Name: ___________________________________
DOB: ________________ Date: __________________
Current Medications
Drug /Food Allergies
Accompanied By
Age
Ht.
Wt.
HC
Pulse
Resp.
Temp.
Interpreter: Y / N
□M
□F
Past Medical History
Interval History
Nutrition
Recent illness: □ Yes □No _____________
□ Breastfeeding
□ Supplementing/Both
Sleep: □ NL______________________
□ Formula (type): ______________________
□ Back to sleep
____________________________________
Reaction to previous IMMS □ Yes □No_____
□ Sleeps in own crib
Frequency: ____________________________
Fruits: □ Yes □No ___ Vegetables: □ Yes
Elimination: □ NL _________________
F/u previous concern: □ None ___________
□No___
Behavior: □ NL ___________________
Meats: □ Yes □No ____ Vitamins:□Yes □No
____________________________________
Car Seat Rear-facing: □ Yes □No _____
Concerns:
Social/ Family History
Growth-Development
Cognitive: □ NL _____________
Language: □ NL ________________
Lives at home with:_________________________________
● object permanence, looks at
● says 2-3 works besides “mama/dada”,
Parent/ child interaction: □ Yes □No ___________________
books, knows “Peek-a-boo”
recognizes name. imitates familiar words
Tobacco smoke exposure: □ Yes □No__________________
Parents working outside home: □ Mother
□ Father
Physical: □ NL _______________
Social: □ NL __________________
Child Care: □ Yes □No
Type: ______________________
● crawling, pulls to standing
● apprehensive with strangers, seeks
Family/ Work Balance: □ Yes □No__________________
parent for play & comfort
WIC:□ Yes □No
Parental Concerns: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Physical Exam (checked □ = normal)
Abnormal Findings
□ General (Alert, NAD)
□ Heart (No murmurs, + femoral pulses)
□ Head (No deformities, symmetric)
□ Lungs (Clear breath sounds)
□ Eyes (PERRL, EOMI, + RR, lids NL,
□ Abdomen (Soft, non-tender)
□ Skin (No rashes)
conjunctivae/sclera clear)
□ Ears (Canals clear, TMs normal,
□ Neuro (Tone, symmetry, strength all NL)
□ Extremities (Full ROM, strength/tone NL,
orients to sounds, voice)
□ Nose (Mucosa NL, patent)
no hip dysplasia)
□ Mouth (MMM, palate intact, lips NL,
□ Genitalia
tongue NL, no oral lesions, teeth:___)
Male (Penis NL: circ/uncir, no adhesions)
□ Throat (No erythema)
Female (Labia/clitoris NL, no discharge)
Assessment
Anticipatory Guidance
□ Discipline (Limit “no”, use descriptors, domestic violence)
□ Well child
□ Normal growth and development
□ Safety (Back to sleep, car seats, avoid smoke exposure, crib safety,
burns, baby-proof home, drowning, poisoning, baby gates)
□ Nutrition (Self-feeding, mealtime routines, table foods, use of cup)
□ Oral Health (Fluoride, wash gums with warm washcloth, teething)
□ Development (Sleep schedule, object permanence, separation anxiety,
temperament, communication, read to baby visual exploration)
Plan
□ Immunizations (See immunization record)
□ Lead Screen
□ Education handout given
Next Appointment: _________________ Signature: ___________________________ Date: _____________
1014.QI.P.FO 10/14
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