General Pediatric Clinic/12 Month Visit
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01068F (01/11)
Reprinted and adapted with permission from Memee K. Chun, M.D.
GENERAL PEDIATRIC CLINIC / 12 MONTH VISIT
nd
(See 2
page for Anticipatory Guidance for 12 Month Visit)
Completion of this form is voluntary.
Patient Name
Date of Birth
Age
Height
Weight
Today’s Date
Accompanied by
Head Circumference
Parental Concerns
Activity
Exploration
Feeding: Milk, type ______________ Amt / day _____________ oz.
Adaptability to Examiner
Breast _____ Bottle _____ Cup _____ Fingers _____
Spoon _____ Solids and Meals / day
Distractibility
Sleeping: Night
Note — Present (+) or Absent (-) as Appropriate
(Cross off parts not examined or not applicable)
Nap
Behavior
Part
N
Abn
Skin: Color, texture, hair, scalp
Review of Family — Social and Health
Head and Face: Symmetry, AF Size _____ cms_____
Eyes: Pupils, conjunctivae, EOM, red reflex
Ears and Nose: Canals, tympanic membranes, turbinates
Nose: Discharge
Parents’ Description of Baby’s Temperament
Mouth: Gums, tongue, # of teeth
Nodes: Cervical, inguinal
Lungs:
Heart: Rhythm, S1, S2, murmur
Problems Identified and Reviewed
Abdomen: Contour, masses, hernia
Genitalia: Vaginal opening, testes ( ) ( )
Extremities: Range of motion, stance
Neuromuscular: Tone, strength, equilibrium, coordination,
Physical and Emotional Status
Gate, DTRs
Diet: Weaning, drop in appetite, table foods.
Describe abnormal findings.
Add citrus fruits
R = Reported
O = Observed
Development Observation
Anticipatory Guidance: Negativism, manipulative behavior, setting
R
O
NO*
NO* = Not observed by parents or examiner
limits, consistency in approach, expectations on toilet training.
G.M.
Stands holding on to furniture
Speech stimulation. Review of fever control and care of minor
Walks holding on to furniture
illnesses.
Stands alone briefly
Safety: Pot handles, stairs, gates, plants, PICA, Car seat, temperature
Stands alone well
taking, lead exposure.
Walks
alone
Stoops and recovers without holding on
Bangs cubes held in two hands
Immunizations
Drug Co. and Lot No.
Expiration Date
Pincer grasp
Scribbles spontaneously
Lang.
Vocalizes and communicates without words
Mama and Dada — nonspecific
Mama and Dada — specific
Blood lead test done
More than two single words
Other Lab tests _________________________________________
P.S.
Plays repetitive games
SIGNATURE — Provider
Date Signed
Plays ball with examiner
Feeds self using fingers
Drinks from cup with help
Comforted by parents' voices
Return to clinic in _____ months.
Quiets at parent's touch
Needs cuddling for reassurance
O = Observed
M = Mother
F= Father
NO* = Not observed here
Parents’ Interactions with Baby
O NO
*
O NO
*
Talks to the baby
Limits activity by physical actions
Responds only when baby cries
Limits activity by verbal command
Allows baby to explore
Voice calm while talking to baby
Sits back during exam
Reinforces behaviors through approval and attention
Watches baby during visit
Other Observations
Development and Parent-Child Interaction
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