Pediatrics — Well-Child Visit Template

Visit Information

Date: [Date]
Visit type: Well-child / Health supervision
Age: [X] years [X] months / [X] weeks (if infant)
Interval since last visit: [X] months

Historian

Information provided by: Mother / Father / Both parents / Guardian / [Other]
Patient present: Yes

Interval History

Parental Concerns

Primary concerns: None / [List concerns]
Questions for today: [Parent/patient questions]

Interim Medical Events

Illnesses since last visit: None / [Details]
Injuries: None / [Details]
Hospitalizations: None / [Details]
ED visits: None / [Details]
Specialist visits: None / [Details, recommendations]
Medication changes: None / [Changes]

Current Medications

[ ] None
[ ] [Medication, dose, frequency, indication]

Allergies

NKDA / [Allergies with reactions]

Growth Assessment

Measurements

Weight: [X] kg ([X] lbs) — Percentile: [X]%
Length/Height: [X] cm ([X] in) — Percentile: [X]%
Weight-for-length (if <2 years): Percentile: [X]%
BMI (if ≥2 years): [X] — Percentile: [X]%
Head circumference (if <3 years): [X] cm — Percentile: [X]%

Growth Trajectory

Weight trend: Tracking appropriately / Crossing percentiles [up/down]
Height trend: Tracking appropriately / Crossing percentiles [up/down]
BMI trend: Normal / Underweight / Overweight / Obese
Concerns: None / [Specify]

Developmental Assessment

Developmental Milestones (Age-Specific)

Infant (0-12 months):

Gross motor: [Rolling, sitting, crawling, pulling to stand, cruising, walking]
Fine motor: [Reaching, grasping, transferring, pincer grasp]
Language: [Cooing, babbling, first words]
Social/emotional: [Social smile, stranger anxiety, object permanence]

Toddler (1-3 years):

Gross motor: [Walking, running, climbing, kicking ball]
Fine motor: [Stacking, scribbling, feeding self]
Language: [Words, phrases, sentences — vocabulary estimate]
Social/emotional: [Parallel play, pretend play, separation anxiety]

Preschool (3-5 years):

Gross motor: [Hopping, throwing, catching]
Fine motor: [Drawing shapes, cutting, dressing self]
Language: [Sentences, questions, storytelling]
Social/emotional: [Cooperative play, sharing, emotional regulation]

School-age (6-12 years):

Academic: [Grade level, performance, learning concerns]
Social: [Friendships, peer relationships]
Activities: [Sports, hobbies, extracurricular]
Behavior: [At home, at school]

Adolescent (12+ years):

Academic: [Grade, performance, future plans]
Social: [Peer relationships, dating]
Activities: [Sports, hobbies, job]
Mental health: [Mood, stress, risk behaviors]

Developmental Screening

Screening tool: [ASQ-3, PEDS, M-CHAT, PHQ-A, etc.]
Score: [Result]
Interpretation: Normal / Concerns in [domains]

Developmental Concerns

Parental concerns: None / [Specific concerns]
Provider concerns: None / [Specific concerns]
Referral needed: No / Yes — [EI, developmental peds, speech, OT, PT]

Nutrition Assessment

Feeding (Age-Specific)

Infant:

Feeding type: Breastfeeding / Formula / Combination

• Breast: [Frequency, duration, concerns]
• Formula: [Type, amount per feed, feeds per day]

Solid foods (if ≥4-6 months): Started / Not started

• Foods introduced: [List]
• Concerns: [Allergies, refusal, etc.]

Vitamin D supplementation: Yes / No
Iron supplementation: Yes / No / N/A

Toddler/Preschool:

Diet: [Variety, concerns]
Milk intake: [Type, amount — goal 16-20 oz/day]
Juice: [Amount — goal <4-6 oz/day]
Water: Adequate / [Concerns]
Picky eating: Yes / No
Appetite: Good / Fair / Poor

School-age/Adolescent:

Diet quality: Good / Fair / Poor
Meals: [Regular family meals, breakfast, etc.]
Fast food: [Frequency]
Sugary beverages: [Frequency]
Fruits/vegetables: [Servings/day]
Concerns: [Disordered eating, excessive intake, etc.]

Sleep Assessment

Total sleep: [X] hours per 24 hours
Bedtime: [Time]
Wake time: [Time]
Naps (if applicable): [Number, duration]
Sleep location: [Own bed, co-sleeping]
Bedtime routine: Established / [Concerns]
Sleep problems: None / [Night waking, difficulty falling asleep, snoring, etc.]
Screen time before bed: Yes / No
Appropriate for age: Yes / No

Elimination (Age-Specific)

Stool pattern: [Frequency, consistency]
Constipation: Yes / No
Urination: Normal / [Concerns]
Toilet training (if applicable): Not started / In progress / Completed

• Day trained: Yes / No
• Night trained: Yes / No

Bedwetting (>5 years): Yes / No — [If yes, frequency]

Safety Screening

Age-Appropriate Safety Topics

[ ] Car seat/booster/seatbelt use — Appropriate for age: Yes / No
[ ] Water safety / Drowning prevention
[ ] Fall prevention
[ ] Poison prevention / Poison control number
[ ] Fire safety / Smoke detectors
[ ] Gun safety — Guns in home: Yes / No — Locked: [Y/N]
[ ] Helmet use (bike, sports)
[ ] Sun safety / Sunscreen
[ ] Stranger safety / Body safety
[ ] Internet safety (older children)
[ ] Driving safety (teens)

Home Environment

Smoke exposure: None / Secondhand / [Details]
Lead exposure risk: Low / High — Screening indicated: Yes / No
Other environmental concerns: None / [Details]

Behavioral/Mental Health Screening

For Older Children/Adolescents:

Depression screening (PHQ-2/PHQ-A): Negative / Positive — Score: [X]
Anxiety screening: Negative / Positive
Substance use (CRAFFT if applicable): Negative / Positive
Suicide risk: None / [Risk level if positive]

Social History

Family Structure

Lives with: [Both parents, single parent, grandparents, etc.]
Siblings: [Ages, health]
Recent family changes: None / [Divorce, new sibling, move, loss]

Childcare/School

Daycare/preschool: Yes / No — [Name, hours]
School: [Grade, school name]
Performance: [Average, above, below, concerns]
IEP/504: No / Yes — [Details]

Screen Time

Daily screen time: [Hours]
Recommendation discussed: Yes (AAP guidelines)

Activities

Physical activity: [Type, frequency]
Extracurricular: [Activities]

Family Medical History

[ ] No significant family history
[ ] Asthma/allergies
[ ] Heart disease (early onset <55 male, <65 female)
[ ] Diabetes
[ ] Cancer
[ ] Mental health conditions
[ ] Developmental disorders
[ ] Other: [Specify]

Physical Examination

Vital Signs

Weight: [X] kg
Length/Height: [X] cm
Head circumference: [X] cm (if <3 years)
BMI: [X] (if ≥2 years)
BP (if ≥3 years): [X/X] — [Normal / Elevated / Stage 1 / Stage 2]
HR: [X]
RR: [X]
Temp: [X]°F (if obtained)

General

Appearance: Well-appearing, age-appropriate
Nutrition: Well-nourished / [Concerns]
Interaction: Age-appropriate / [Concerns]

HEENT

Head: Normocephalic, atraumatic / Fontanelle: [If applicable — open/closed, flat/bulging]
Eyes: Red reflex present / PERRL / Extraocular movements intact / [Strabismus, etc.]
Ears: TMs clear bilaterally / [Effusion, retraction, etc.]
Nose: Patent / [Congestion, etc.]
Throat: Oropharynx clear / [Tonsils — grade, etc.]
Teeth: [Age-appropriate eruption, caries, dental hygiene]

Neck

Supple, no lymphadenopathy / [Findings]

Cardiovascular

RRR, no murmur / [Murmur: grade, location — innocent vs pathologic]
Femoral pulses: Present / [Concerns]

Respiratory

Clear to auscultation / [Findings]
No respiratory distress

Abdomen

Soft, non-tender, non-distended / [Findings]
No hepatosplenomegaly
Umbilicus: Normal / [Hernia]

Genitourinary

Male:

Testes: Descended bilaterally / [Undescended — R/L]
Phimosis: None / [Physiologic/pathologic]
Hernia: None / Present
Tanner stage: [I-V]

Female:

External genitalia: Normal / [Findings]
Tanner stage: [I-V]
Menstrual history (if applicable): [Age of menarche, LMP, concerns]

Musculoskeletal

Gait: Normal / [Concerns]
Spine: Straight / Scoliosis [degrees]
Hips: Stable, full ROM / [DDH concerns if infant]
Extremities: Symmetric, no deformity

Skin

Clear / [Birthmarks, rashes, etc.]

Neurological

Tone: Normal / [Hyper/hypotonia]
Strength: Symmetric
DTRs: Symmetric
Developmental: Grossly age-appropriate / [Concerns]

Screening Tests

Vision

Screening performed: Yes / No / Referred
Method: [Red reflex, cover test, visual acuity — R: 20/X, L: 20/X]
Result: Pass / Refer

Hearing

Screening performed: Yes / No / Referred
Method: [OAE, pure tone audiometry]
Result: Pass / Refer

Laboratory

[ ] Newborn screen: Complete / Pending / [Abnormal results]
[ ] Lead level (9-12 months, high risk): [Result] / Not indicated
[ ] Hemoglobin/Hct (9-12 months): [Result] / Not indicated
[ ] Lipid screening (9-11 years or risk factors): [Result] / Not indicated
[ ] Other: [Specify]

Immunizations

Due Today

[ ] DTaP/Tdap — Dose [X]
[ ] IPV — Dose [X]
[ ] Hib — Dose [X]
[ ] PCV13/PCV15 — Dose [X]
[ ] Rotavirus — Dose [X]
[ ] Hepatitis B — Dose [X]
[ ] MMR — Dose [X]
[ ] Varicella — Dose [X]
[ ] Hepatitis A — Dose [X]
[ ] Influenza — [Annual]
[ ] HPV — Dose [X]
[ ] MenACWY — Dose [X]
[ ] MenB — Dose [X]
[ ] COVID-19 — Dose [X]

Administered Today

[List vaccines given with lot numbers, sites, VIS date]

Deferred/Refused

[ ] None
[ ] [Vaccine] — Reason: [Illness, allergy, parental refusal]

Catch-up Needed

[ ] Up to date
[ ] Catch-up: [Vaccines needed]

Assessment

1) Well-child visit — [Age]
2) Growth: [Normal / Overweight / Underweight / Failure to thrive]
3) Development: [Age-appropriate / Concerns: specify]
4) [Additional diagnoses if applicable]

Plan

Anticipatory Guidance (Age-Specific)

Topics discussed:

• [ ] Nutrition: [Age-specific guidance]
• [ ] Safety: [Age-specific topics]
• [ ] Development: [What to expect, stimulation]
• [ ] Sleep: [Age-appropriate recommendations]
• [ ] Dental care: [Brushing, fluoride, dental home]
• [ ] Physical activity
• [ ] Screen time limits
• [ ] Discipline/behavior
• [ ] School readiness (if applicable)
• [ ] Puberty (if applicable)
• [ ] Risk behaviors (adolescents)

Referrals

[ ] None needed
[ ] Early intervention
[ ] Developmental pediatrics
[ ] Speech therapy
[ ] Occupational therapy
[ ] Physical therapy
[ ] Ophthalmology
[ ] Audiology
[ ] Dentist
[ ] Nutrition/dietitian
[ ] Mental health
[ ] Other: [Specify]

Follow-up

Next well-child visit: [Age/timeframe]

• [2 months / 4 months / 6 months / 9 months / 12 months / 15 months / 18 months / 24 months / 30 months / 3 years / Annual]

Sooner if: Developmental concerns, illness, parental concerns

Handouts Provided

[ ] Age-appropriate handout
[ ] Vaccine information statements (VIS)
[ ] Developmental milestones
[ ] Safety handout
[ ] [Other]