Dr. MJ Bazos, MD
12 MONTH Checkup
PATIENT NAME __________________________ DATE ________ DOB _________
Nursing Assessment: Temp _______ DRUG ALLERGIES
Weight _______ Percentile _______ Length _______ Percentile ________
FOC _______ Percentile _______ _______

Stands with support Clasps hands _____ Waves “Good-bye” Cruises, Walks yes/no
Interval History:
Parental Concerns: ____________________________________________________
Follows a command Points at objects
Imitates sounds Understands names
Plays “peek-a-boo” Turns pages
Sleep Pattern/Position? _______________ Drinks from a cup Says “mama”, “dada”, “baba”
Stools: Consistency/Frequency:__________________ Enjoys games

May switch to Whole Milk and Regular Table Foods
System Normal Abnormalities
Adequate Weight Gain ?_________ General _________________ Food Allergies?_____
Fluoride Supplementation? ______Head ____________Fontanelle ______ EENT ______ Neck____ Chest ____________ Lungs _____________ Heart ______ ____________ Abdomen ________________ Genitalia ___________
Back/Spine ___________ Extremities _________ Hips _____________
Skin ______________ Neurologic ______________

Social History: Primary Caregiver ___________Persons present in household? _________
Any changes ?_________________ Immunodeficient household contacts? ____________ Day Care Center ? ________________________

Family Medical History: Family member with TB? __Child at Lead Exposure Risk? ___ ___

Discontinue bottle Crib safety Baby bottle tooth decay
Decrease in appetite Milk and honey now okay No toys with small parts
No nuts or popcorn Rolling off high places No plastic bags / marbles
Childproof home Do not leave alone with sibling Syrup of Ipecac / Poisonings
Water temperature No smoking in home Acetaminophen after shots
Car Seat / Air Bags Sun exposure Water / Pool safety

Immunizations: Follow-up visit:
MMR, Varicella