12 month check-up

Patient: Lucas  
PHIN#:  
Date: 2026-02-10  
12 MONTH CHECK-UP  
Seen with parent.

Subjective:  
Concerns:  
1. Parental concern regarding Lucas's increased fatigue and difficulty falling asleep despite going to bed at 9:30 PM.  
2. Parental observation of reduced appetite, with Lucas eating little in the morning and not always finishing his lunch.

Family history:  
No family history concerns mentioned.

Lifestyle/Social history:  
Lucas is physically active and enjoys participating in basketball. No other relevant lifestyle or social factors were discussed.

Significant Past Medical History:  
No significant past medical history mentioned.

Allergies:  
No allergies mentioned.

Medications:  
Lucas is currently taking a 40 milligram dose of medication for attention-deficit/hyperactivity disorder.

Nutrition:  
Lucas consumes breakfast in small amounts and brings lunch to school, though he does not always finish it. Occasional intake of soda is reported, with advice given to switch to no-sugar sparkling water.

Feeding problems:  
No mention of feeding problems.

Elimination:  
No elimination issues mentioned.

Development:  
No developmental delays mentioned.

Sleep:  
Lucas reports difficulty initiating sleep despite going to bed by 9:30 PM. Increased fatigue is noted.

Dental:  
No dental concerns mentioned.

Child care arrangement:  
No child care arrangement concerns mentioned.

Objective:  
Physical Examination:  
Appears well, alert, in no distress  
Head and Neck: Normal  
Eyes: Normal Red reflexes: Yes  
ENT: Normal  
Neck: No masses  
Heart sounds: Normal  
Chest: Normal  
Abdomen: Normal  
Hips: Normal  
Genitalia: Normal  
Tone: Normal  
Diaper rash: No  
Skin: Normal  
SPINE : Normal

Assessment:  
Well child

Plan:  
Immunizations: None administered at this visit.  
Anticipatory guidance, advice, and education provided as per Rourke Baby Record Guide.  
Discussion of immunizations and potential side effects conducted in accordance with provincial and NACI guidelines, including Influenza vaccine.  
Follow-up scheduled at 18 months of age.