Well Child SOAP Note
ID: “M,” born on January 24, 2009, 13 years old, Caucasian female. She presented today for an appointment at the clinic alone M appears to be a valid source of information.
Subjective:
CC: “here today for a routine well-child visit.”
HPI: 13-year-old Caucasian female presents to the clinic today alone for well-child visit. M seems to be in good spirits and sitting on the chair. M reports that her last visit was one year ago. No lab work was done in the previous visit.
Childhood vaccinations and flu shot vaccinations are up to date. Last dental exam was four months ago
PMH:
General Health: M denies any new health conditions that have occurred since the last visit.
Psychiatric: M denies
Surgery: M denies
Allergies: M reports that she has an allergy to peanuts. And that when she eats peanut, she
developed a rash and her throat swell. She uses Epi-pen for her allergy.
Medications: Epi-pen PRN, Flintstone vitamin
Family History: Maternal grandmother is alive and well. Maternal grandfather has hypertension.
Father is alive and well, and the mother has no medical history. M is not aware of any medical history on the father’s side.
