Pediatric Wellness Checkup Template

Subjective:  
- Reason for visit: Routine well child examination  
History of Present Illness:  
- Current concerns or lack thereof: No current issues, child is healthy and active  
Past Medical History:  
- Relevant past medical conditions and their status: No notable past medical history  
Medication History:  
- Current medications or lack thereof: Not on any medications  
Allergies:  
- Known drug allergies or lack thereof: No known drug allergies  
Immunizations:  
- Vaccination status: Up to date  
Growth and Development:  
- Developmental screening results: Normal  
- Developmental milestones: Achieving all milestones  
- Potty training status: Fully potty trained  
Diet and Nutrition:  
- Appetite description: Good appetite  
- Variety of foods consumed: Balanced diet including fruits, vegetables, and proteins  
- Milk intake: 2 cups of milk daily  
Social History:  
- Living situation: Resides with parents and one sibling  
- Home environment safety: Home is childproofed  
Family History:  
- Significant family history or lack thereof: No significant family history  
Objective:  
Vital Signs:  
- Weight and percentile: 15 kg (50th percentile)  
- Height and percentile: 95 cm (50th percentile)  
- BMI and percentile: 16 (50th percentile)  
Physical Examination:  
- General appearance: Well-nourished, active  
- Skin examination: No rashes or lesions  
- HEENT examination:  
  - Ear examination: Tympanic membranes clear  
  - Mouth examination: Oral mucosa pink, no lesions  
  - Neck examination: Supple, no lymphadenopathy  
- Chest/Lungs examination: Clear to auscultation bilaterally  
- Cardiovascular examination: Regular rate and rhythm, no murmurs  
- Abdomen examination: Soft, non-tender  
- Musculoskeletal examination: Full range of motion, no deformities  
- Neurological examination: Alert, oriented, normal reflexes  
Screenings:  
- Vision screening result: Passed  
- Hearing screening result: Passed  
- Lead screening result: Negative  
- Developmental screening result: Normal  
Assessment:  
- Overall assessment of well child exam: Healthy child, no concerns  
- Growth assessment: Appropriate growth for age  
- Development assessment: Meeting developmental milestones  
Plan:  
- Vaccinations administered: None needed today  
- Anticipatory guidance:  
  - Language development recommendations: Encourage reading and storytelling  
  - Play and peer interaction recommendations: Engage in group play activities  
  - Car seat recommendations: Use forward-facing car seat  
  - Safety recommendations: Supervise outdoor play  
  - Dental care recommendations: Brush teeth twice daily  
  - Sleep recommendations: 10-12 hours of sleep per night  
  - Nutrition recommendations: Continue balanced diet  
  - Follow-up recommendations: Return in 6 months for next well child visit  
Health Promotion:  
- Handouts provided: Nutrition and safety tips  
- Topics discussed: Importance of physical activity  
- Safety measures reviewed: Helmet use for biking