9 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 Name
Last Name
Patient's date of birth
*
-
Month
-
Day
Year
Date
Name of person filling out form
*
First Name
Last Name
Relationship to patient
*
mother
father
grandparent
foster parent
other relative
TELL US ABOUT YOUR BABY AND FAMILY.
What excites or delights you most about your baby?
Does your baby have special health-care needs?
No
Yes
Have there been major changes lately in your baby’s or family’s life?
No
Yes
Have any of your baby's relatives developed new medical problems since your last visit?
No
Yes
Unsure
Does your baby live with anyone who smokes or spends time in places where people smoke or use e-cigarettes?
No
Yes
Unsure
YOUR GROWING AND DEVELOPING BABY
Do you have specific concerns about our baby's development, learning or behavior?
No
Yes
Check off each of the tasks that your baby is able to do.
RISK ASSESSMENT
HEARING: Do you have any concerns about how your baby hears?
No
Yes
Unsure
LEAD: Does your baby live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or that was renovated in the past 6 months?
No
Yes
Unsure
ORAL HEALTH: Does your baby's primary water source contain fluoride?
Yes
No
Unsure
VISION: Do you have concerns about how your baby sees?
Yes
No
Unsure
VISION: Do your baby's eyes appear unusual or seem to cross?
No
Yes
Unsure
VISION: Do your baby's eyelids droop or does one eyelid tend to close?
No
Yes
Unsure
VISION: Have your baby's eyes ever been injured?
No
Yes
Unsure
DO YOU HAVE ANY CONCERNS YOU WISH TO DISCUSS FURTHER WITH US?
Yes
No
Submit
Should be Empty: