Well child – 12 mo

HISTORY: [textarea cols=80 rows=1][checkbox name="informant" value="provided by parent|provided by other|unobtainable d/t parental anxiety and/or lack of knowledge|interpretation provided by family member|interpretation provided by MA"]
SPECIAL NEEDS: [textarea cols=80 rows=1][checkbox name="special" value="none|specialty"]
SOCIAL HISTORY: [textarea cols=80 rows=1][checkbox name="risk" value="no changes|child care|housing|single parent|working parent|siblings"]

REVIEW OF SYSTEMS
Interval change: [textarea cols=80 rows=1][checkbox name="concerns" value="doing well, no changes since last visit|no illnesses or injuries|no specific concerns raised|no visits to health care providers, facilities|questionnaire provided & reviewed"]
Nutrition: [textarea cols=80 rows=1][checkbox name="nutrition" value="no concerns"]
Elimination: [textarea cols=80 rows=1][checkbox name="elimination" value="no concerns"]

GROWTH: [textarea cols=80 rows=1][checkbox name="weight" value="chart provided, reviewed, developing well"]
MILESTONES: [textarea cols=80 rows=1][checkbox name="milestones" value="stands alone, cruises|points, bangs toys together, drinks from cup, feeds self|ways bye-bye, looks for dropped or hidden objects, cries when parent leaves, plays peekaboo|imitates vocalizations, speaks 1 to 2 words, follows simple directions"]

=========================================

Appearance: [textarea cols=80 rows=1][checkbox name="appearance" value="well-appearing|active, interactive|no distress|uncooperative with exam"]
Skin: [textarea cols=80 rows=1][checkbox name="skin" value="pink, normal turgor|no rashes|no bruises"]
Head: [textarea cols=80 rows=1][checkbox name="head" value="no skull deformities|plagiocephaly"]
Eyes: [textarea cols=80 rows=1][checkbox name="eyes" value="red reflex bil, ocular alignment appears normal"]
Ears: [textarea cols=80 rows=1][checkbox name="ears" value="appears to hear|normal canals & TMs"]
Nose: [textarea cols=80 rows=1][checkbox name="nose" value="normal exam"]
Mouth: [textarea cols=80 rows=1][checkbox name="mouth" value="oral mucosa moist & without lesions|teeth present, no caries"]
Throat: [textarea cols=80 rows=1][checkbox name="throat" value="w/o swelling or exudates"]
Neck: [textarea cols=80 rows=1][checkbox name="neck" value="supple, no LAD"]
Chest: [textarea cols=80 rows=1][checkbox name="chest" value="unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally"]
Heart: [textarea cols=80 rows=1][checkbox name="heart" value="regular rate & rhythm, no murmurs"]
Abdomen: [textarea cols=80 rows=1][checkbox name="abdomen" value="soft, nondistended, nontender, no obvious palpable masses"]
Genitalia: [textarea cols=80 rows=1][checkbox name="genitalia" value="normal appearance|uncircumcised| circumcised|testes down bilaterally"]
Musculoskeletal: [textarea cols=80 rows=1][checkbox name="extremities" value="symmetrical FROM, normal spine"]
Neuro: [textarea cols=80 rows=1][checkbox name="neuro" value="normal reflexes, normal & symmetrical tone/strength"]

===========================================

LABORATORY/OFFICE DIAGNOSTICS: [textarea cols=60 rows=1][checkbox name="office_diag" value="Hgb/Lead normal|Hgb/Lead to be ordered|per WIC"]

IMMUNIZATION: [textarea cols=80 rows=1][checkbox name="immunization" value="per schedule|deferred|declined"]

OUTSIDE ORDERS/REFERRALS: [textarea cols=80 rows=1][checkbox name="orders" value="none|laboratory studies|diagnostic studies|specialty|WIC"]

DISCUSSED AND/OR HANDOUT GIVEN/OFFERED: [textarea cols=80 rows=1][checkbox name="guide" value="safety, childproof home, bike helmet, poisons, water safety, sunscreen|age-appropriate discipline, consistent routine, nap and bedtime, limit but enforce rules, praise toddler, distraction as discipline|family meals, self-feeding, drink form cup, food variety, limit bottle, limit sugar, brush teeth, first dental exam"]

FOLLOW UP: [textarea cols=80 rows=1][checkbox name="follow" value="15 months of age, sooner if concerns arise"]