Family Medicine Specialist Template

Well Child Check

A professional Family Medicine Specialist template for healthcare professionals.

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Specialty

Family Medicine Specialist

Used

85 times

Type

Note

Last edited

23/05/2025

Created by

Cannon Nelson

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About this template

The 'Well Child Check - Cannon' template is a comprehensive documentation tool designed for family medicine specialists conducting routine pediatric evaluations. This template facilitates the recording of key aspects of a child's health, including growth metrics, developmental milestones, dietary habits, and social history. It also includes sections for a detailed review of systems, physical examination findings, and anticipatory guidance. By using this template, clinicians can ensure a thorough assessment of a child's well-being, track developmental progress, and provide tailored health advice. This template is ideal for capturing the nuances of pediatric care in a structured format.

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Chief Complaint: - Routine well child check HPI: 1. The child has been in good health with no recent illnesses. 2. Parents have noted normal developmental progress. 3. No parental concerns at this time. Social History: - Lives with both parents and a sibling. - Attends daycare three times a week. - No recent changes in home environment. Growth and Vital Signs: Weight: 10 kg (50th percentile) Length/Height: 75 cm (50th percentile) Head Circumference (FOC): 45 cm (50th percentile) BMI: 16 (50th percentile) Blood Pressure: Not applicable Pulse Oximetry: Not applicable Developmental Assessment: 12 Months: Walking with support, first words, social interaction Dietary History: - Currently on a mixed diet of breast milk and solids. - Transitioning to whole milk. - Uses a sippy cup. Review of Systems: Constitutional: No fever, chills, fatigue, or weight changes. Eyes: No vision changes, redness, pain, or discharge. Ears, Nose, Throat: No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia. Cardiovascular: No chest pain, palpitations, or edema. Respiratory: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain. Genitourinary: No dysuria, hematuria, urinary frequency, or urgency. Musculoskeletal: No joint pain, stiffness, or swelling. Skin: No rashes, lesions, or itching. Neurologic: No headaches, dizziness, numbness, or weakness. Psychiatric: No anxiety, depression, or mood changes. Endocrine: No polyuria, polydipsia, or heat/cold intolerance. Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy. Allergic/Immunologic: No allergies, sneezing, or hives. Physical Exam: Constitutional: Well-nourished, active, and alert. Vital Signs: Within normal limits. Head: Normocephalic, atraumatic. Eyes: PERRLA, EOMI. Ears, Nose, Throat: Tympanic membranes clear, no nasal discharge, throat clear. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Gastrointestinal: Soft, non-tender, no organomegaly. Musculoskeletal: Full range of motion, no deformities. Skin: No lesions or rashes. Neurologic: Grossly intact. Screenings: - Hearing and vision screenings performed, normal results. Vaccinations: - Up-to-date. Anticipatory Guidance: - Discussed sleep safety, car seat use, and dental hygiene. - Advised on limiting screen time and encouraging physical activity. Specialist Care: - None required at this time. Assessment & Plan: Well Child Check Assessment: The child is developing appropriately for age, meeting all milestones. Vaccinations are up-to-date. No concerns noted. Plan: - Continue current diet and introduce more solids. - Encourage physical activity and social interaction. - Schedule next well visit in 3 months. Follow-up: Return in 3 months for the next well child check.