2 Year 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 CHILD AND FAMILY
What excites or delights you most about your child?
Does your child have special health care needs?
No
Yes
Please describe:
Have there been major changes lately in your child's family's life?
No
Yes
Please describe:
Have any of your child's relatives developed new medical problems since your last visit?
No
Yes
Unsure
If yes or unsure, please describe:
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
No
Yes
Unsure
YOUR GROWING AND DEVELOPING CHILD
Check off each of the tasks that your child is able to do.
RISK ASSESSMENT
ANEMIA: Does your child's diet include iron-rich foods, such as meat, iron-fortified cereals, or beans?
Yes
No
Unsure
ANEMIA: Do you ever struggle to put food on the table?
DYSLIPIDEMIA: Does your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (male) or 65 (female)?
No
Yes
Unsure
DYSLIPIDEMIA: Does your child have a parent with elevated blood cholesterol level (240 mg/dL or higher) or who is taking chloesterol medication?
No
Yes
Unsure
HEARING: Do you have concerns about how your child hears?
No
Yes
Unsure
HEARING: Do you have concerns about how your child speaks?
No
Yes
Unsure
LEAD: Does your child 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 was renovated in the past 6 months?
No
Yes
Unsure
ORAL HEALTH: Does your child have a dentist?
Yes
No
Unsure
ORAL HEALTH: Does your child's primary water source contain fluoride?
Yes
No
Unsure
TUBERCULOSIS: Was your child 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)?
No
Yes
Unsure
TUBERCULOSIS: Has your child had close contact with a person who has tuberculosis disease or who has a positive tuberculosis test result?
No
Yes
Unsure
TUBERCULOSIS: Has your child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
No
Yes
Unsure
VISION: Do you have concerns about how your child sees?
No
Yes
Unsure
VISION: Do your child's eyes appear unusual or seem to cross?
No
Yes
Unsure
VISION: Do your child's eyelids droop or does one eyelid tend to close?
No
Yes
Unsure
VISION: Have your child's eyes ever been injured?
No
Yes
Unsure
Submit
Should be Empty: