1 Month Previsit Questionnaire

1 Month Previsit Questionnaire

To provide you and your child with the best possible care, we would like to know how things are going. Please answer all the questions. Thank you.
Patient's Name*

First NameLast Name
Patient's date of birth*

MonthDayYear
Date
Name of person filling out form*

First NameLast Name
Relationship to patient*
Vaccines for Children (VFC) Screen
TELL US ABOUT YOUR BABY AND FAMILY.
What excites or delights you most about your baby?
Does your baby have special health care needs?
Have there been major changes lately in your baby's or family's life?
Have any of your baby's relatives developed new medical problems since your last visit?
Does your baby live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
YOUR GROWING AND DEVELOPING BABY
Do you have specific concerns about your baby's development, learning, or behavior?
Check off each of the tasks that your baby is able to do.
RISK ASSESSMENT
TUBERCULOSIS: Was your baby or any household member born in, or has he or she traveled to a country where tuberculosis is common (this includes countries in Africa, Asia, Latin America, and Eastern Europe)?
TUBERCULOSIS: Has your baby had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
VISION: Do you have concerns about how your baby sees?
EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)
1. I have been able to laugh and see the funny side of things*
2. I have looked forward with enjoyment to things*
3. I have blamed myself unnecessarily when things went wrong*
4. I have been anxious or worried for no good reason*
5. I have felt scared or panicky for no very good reason*
6. Things have been getting on top of me*
7. I have been so unhappy that I have had difficulty sleeping*
8. I have felt sad or miserable*
9. I have been so unhappy that I have been crying*
10. The thought of harming myself has occured to me*
TOTAL SCORE (a score of 10 or greater suggests possible maternal depression):
1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .

2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199
DO YOU HAVE ANY CONCERNS YOU WISH TO DISCUSS FURTHER WITH US?
Should be Empty: