Visit Documentation Forms: 12 Months Visit

Name

ID Number

Date of Borth

Age

Accompanied By

Preferred Language

Date and Time

Weight (%)

Length (%)

HC (%)

Weight-for-length (%)

Vital if (Indicated)

Temp

Resp Rate

Spo2

HISTORY

Concerns and Questions

Interval History

Medical History

Child has special health care needs.

Areas reviewed and updated as needed.

Past Medical History (See Initial History Questionnaire.)

Surgical History (See Initial History Questionnaire.)

Problem List (See Problem List.)

Medications

Reviewed and updated (See Medication Record.)

Allergies

No known drug allergies

Nutrition

Good appetite

Good variety

Solids

Breastfeeding

Formula

Milk

Ounces per 24 hours

If yes, please describe

If other, please specify

Elimination: Regular soft stools

Sleep: No Concerns

Behavior (If no concerns, please skip)

Physical Activity

Screen time

None

Screen time (If none, please skip)

Source

DEVELOPMENT

Normal development

See Previsit Questionnaire

If yes, specify

SOCIAL LANGUAGE AND SELF-HELP

Looks for hidden objects
Imitates new gestures

VERBAL LANGUAGE

Says, “Dad” or “Mom” with meaning
Uses one word other than Mom or Dad, or personal names
Follows a verbal command that includes a gesture

GROSS MOTOR

Takes first independent steps
Stands without support

FINE MOTOR

Drops object in a cup
Picks up small object with 2-finger pincer grasp
Picks up food and eats it

SOCIAL AND FAMILY HISTORY

Areas reviewed and updated as needed (See Initial History Questionnaire.)

Social History

Family History

Changes since last visit

No interval change

Smoking household

Yes

If yes, specify

Firearms in home

Yes

If yes, specify

Observation of parent-child interaction

If yes, specify

REVIEW OF SYSTEMS

A 10-point review of systems was performed and results were negative except for any positive results listed below.

Required Field = Focus area for this Bright Futures Visit

Constitutional

Respiratory

Skin

Eyes

Gastrointestinal

Neurological

Head, Ears, Nose, and Throat

Genitourinary

Other

Cardiovascular

Musculoskeletal

Other

PHYSICAL EXAMINATION

System examined

Required Field = Focus area for this Bright Futures Visit

Normal examination findings in text. Cross out abnormalities. Describe other findings in the area provided.

General: Alert, active child. Normal interval growth in height, weight, and head circumference. Normal weight-for-length for age.

Head: Normocephalic and atraumatic. Normal sutures. Anterior fontanelle open and flat.

Eyes: Fixes and follows. Extraocular eye movements intact. No strabismus. Red reflex present bilaterally. No opacification. Normal funduscopic examination findings.

Ears, nose, mouth, and throat: Tympanic membranes with visible light reflex bilaterally. Healthy-appearing teeth without caries, plaque, or discoloration.

Neck: Supple, with full range of motion and no significant adenopathy.

Heart: Regular rate and rhythm. No murmur.

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing.

Abdomen: Soft, with no palpable masses.

Genitourinary:

Normal female external genitalia. Labia open.

Normal male external genitalia, with testes descended bilaterally.

Musculoskeletal: Spine straight. Normal hip abduction.

Neurological: Moves all extremities equally. Normal hand grasp and strength. Age-appropriate gait (If walking).

Skin: Warm and well perfused. No lesions (atypical nevi, café-au-lait spots, or birthmarks) or bruising.

Other comments:

ASSESSMENT

Well child

Normal interval growth (See growth chart.)

Normal weight-for-length percentile for age

Age-appropriate development

ANTICIPATORY GUIDANCE (Discussed and/or handout given)

SOCIAL DETERMINANTS OF HEALTH

Living situation and food security
Tobacco, alcohol, and drug use
Social connections with family and others

ESTABLISHING ROUTINES

Adjustment to development changes and behavior
Family time
Bedtime, nap time, and teeth brushing
Media

SAFETY

Car safety seats
Falls
Drowning prevention and water safety
Sun protection
Pets
Poisoning

ESTABLISHING A DENTAL HOME

First dental checkup and dental hygiene

FEEDING AND APPETITE CHANGES

Self-feeding
Continued breastfeeding; transition to family meals
Nutritious foods

PLAN

(Immunization) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Anemia (Result)

Within reference range

Low

Follow-up

Lead (Medicaid or high prevalence area)

Pending/sent to lab

Result

Within reference range

Elevated

Follow-up

Oral health

If yes, specify

Selective Screening (based on risk assessment) (See Previsit Questionnaire.):

Hearing

Oral Health

Lead (non-Medicaid or low prevalence area)

Tuberculosis

Vision

Comments/results

Formatted text

Follow-up

Routine follow-up at 15 months

Next Month

Referral to

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