Name_____________
Date______________
12 month
12 Month WCC
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Parents working outside home ____mother ____father
Child Care ____yes ____no Type______________________________________
Changes since last visit _________________________________________________
Diet
Milk ____________________________________
Type ____________________________________
Milk Amount/Time____________________________________
Solid Food Comments _______________________________________________
Source of water ______________ Vitamins/Fluoride___________
Bowel/Bladder
Stool Concerns ____yes ____no
Stool Consistency ____hard ____soft
Urination Concerns ____yes ____no
Sleep
Back sleeping ____yes ____no
Location ____co-sleep ____crib ____co-sleep & crib
Duration ____ < 3 hrs ____ 3-6 hrs ____ > 6 hrs
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Activity (play time, no TV) ____________________________________________________
Development
Social Emotional: ___ Waves bye-bye ___Tries to do what you do
___Cries when you leave ___Plays peekaboo
___Hands you a book to read
Communication: ___ Speaks 1 to 2 words ___Babbles
___ Tries to make the same sounds you do
___Looks at things you are looking at
Cognitive: ___Follows simple directions
Physical : ___Bangs toys together ____Pulls to stand
___Stands alone ___Drinks with a cup
Additional comments: ____________________________________________________________
________________________________________________________________________________
