Sav’s Well Child Template

[textarea name="variable_1" fillable="true"]HISTORY OF PRESENT ILLNESS:
Parental questions/concerns:

Illness/surgeries since last visit: 

Dental hygiene:

No other significant health concerns at this time.
[textarea name="variable_2"]REVIEW OF SYSTEMS:
All systems reviewed and negative except as noted per HPI.[/textarea]
[textarea name="variable_3" fillable="true"]PHYSICAL EXAMINATION:
General: Well appearing, well nourished, well developed and age appropriate. Well groomed, interactive in no acute physical or emotional distress. Vitals reviewed and stable.

Skin: Appropriate for ethnicity, warm, dry, normal turgor and without rashes.

Head: Normocephalic, atraumatic.

Eyes: Sclerae clear, no visible drainage, eyelid edema or erythema. PERRLA bilaterally. 

Ears: Tympanic membranes pearly-grey with good light reflex and visible landmarks bilaterally. 

Nose: Nose clear, inferior turbinates normal bilaterally, septum midline and intact.

Oral cavity and pharynx: Mucous membranes moist. Palate clear and intact. Dentition normal for age. Uvula midline, no oral lesions, posterior oropharynx clear. Tonsils non-erythematous or edematous without exudate, vesicles, or ulcerations bilaterally.

Lymph: No significant lymphadenopathy appreciated. 

Cardiovascular: Regular rate and rythm. Normal S1 and S2. No murmurs, gallops, or rubs. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused, without clubbing, cyanosis or edema. Distal capillary refill is less than 2 seconds.

Lungs: Unlabored respirations. Normal rate. Symmetric chest expansion. Breath sounds clear to auscultation bilaterally. No wheezes, crackles, rales, rhonchi, or retractions. 

MSK: Normal active and passive ROM.

Neuro: Alert, no focal deficits observed.[/textarea]
[textarea name="variable_4" fillable="true"]ASSESSMENT: 
Normal growth and development, thriving.

Anticipatory guidance: We talked about ***
Ctrl + (or )

Ctrl + (or )

Ctrl + (or )

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 4 form elements, 4 text areas, 4 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: