Well Child Report Form

Well Child Report Child's Information Name: [child's full legal name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Date of Birth: [child's date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Age: [child's age in years and months] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Gender: [child's gender] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Parent/Guardian Information Name(s): [full name(s) of parent(s) or guardian(s)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Contact Number: [parent/guardian's primary contact telephone number] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Email: [parent/guardian's email address] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Date of Examination: [date of the current well child examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Reason for Visit: [description of the purpose of the visit, including routine check-up, specific concerns, or follow-up] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Developmental Milestones Gross Motor: [description of gross motor skills achieved, such as walking, running, jumping, climbing, and coordination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Fine Motor: [description of fine motor skills achieved, such as grasping, drawing, writing, and manipulating small objects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Language/Communication: [description of language development, including vocabulary, sentence formation, understanding instructions, and expressive communication] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Social/Emotional: [description of social interactions, emotional regulation, play skills, and attachment behaviors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Cognitive: [description of problem-solving abilities, memory, attention span, and learning skills] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Physical Examination Findings General Appearance: [description of overall appearance, including alertness, activity level, and nutritional status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Head: [findings related to head circumference, fontanelles, and scalp] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Eyes: [findings related to vision, eye alignment, and ocular health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Ears: [findings related to hearing, ear canals, and tympanic membranes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Nose/Throat: [findings related to nasal passages, oral cavity, tonsils, and pharynx] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Cardiovascular: [findings related to heart sounds, rhythm, and peripheral pulses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Respiratory: [findings related to breath sounds, respiratory effort, and lung fields] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Abdomen: [findings related to abdominal contour, tenderness, and bowel sounds] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Genitourinary: [findings related to external genitalia and any relevant concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Musculoskeletal: [findings related to range of motion, muscle tone, strength, and gait] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Skin: [findings related to skin integrity, rashes, lesions, and birthmarks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Neurological: [findings related to reflexes, cranial nerves, and overall neurological function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Growth Parameters Weight: [child's current weight and percentile] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Height/Length: [child's current height or length and percentile] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) BMI (if applicable): [child's current Body Mass Index and percentile] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Immunization Status: [details of immunizations received, including dates and types, and any upcoming immunizations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Screening Tests Vision Screening: [results of vision screening] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Hearing Screening: [results of hearing screening] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Developmental Screening: [results of developmental screening tools used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Other Screenings: [results of any other relevant screenings, such as lead, anemia, or tuberculosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Anticipatory Guidance/Counselling Nutrition: [advice and recommendations regarding healthy eating habits, dietary needs, and introduction of new foods] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Safety: [advice and recommendations regarding child safety, including car seat safety, home safety, water safety, and injury prevention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Sleep: [advice and recommendations regarding sleep patterns, sleep hygiene, and addressing sleep disturbances] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Discipline/Behavior: [advice and recommendations regarding age-appropriate discipline strategies, managing challenging behaviors, and promoting positive behavior] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Developmental Promotion: [advice and recommendations on activities and strategies to promote cognitive, social, and emotional development] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Oral Health: [advice and recommendations regarding dental hygiene, fluoride, and first dental visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) School Readiness (if applicable): [advice and recommendations regarding preparation for school, social skills, and academic readiness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Concerns/Recommendations Parental Concerns: [summary of any concerns expressed by the parent(s) or guardian(s)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Provider Recommendations: [recommendations from the healthcare provider, including follow-up appointments, referrals, or specific interventions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Next Well Child Visit Due: [date or age when the next well child visit is recommended] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Signature: _________________________" "Printed Name: [provider's full name]" "Date: [date of report completion]" (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)