15 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
*
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
Have there been major changes lately in your child's or family's life?
No
Yes
Have any of your child's relatives developed new medical problems since your last visit?
No
Yes
Unsure
YOUR GROWING AND DEVELOPING CHILD
Do you have specific concerns about your child's development, learning or behavior?
No
Yes
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?
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
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
DO YOU HAVE ANY CONCERNS YOU WISH TO DISCUSS FURTHER WITH US?
Yes
No
Submit
Should be Empty: