3 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
Vaccines for Children (VFC) Eligibility Screen:
My child has Medicaid insurance.
My child does not have insurance.
My child is a Native American or Alaskan Native
My child's health insurance has limited or no coverage for administration of vaccines.
My child has private insurance.
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
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
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?
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 six months?
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: Where is your child or any household member born in, or has he or she travel to, a country where turkey losses is common parentheses this includes countries in Africa, Asia, Latin America, and eastern Europe)??
No
Yes
Unsure
TUBERCULOSIS: As a child had close contact with a person who has tuberculosis disease?
No
Yes
Unsure
DO YOU HAVE ANY CONCERNS YOU WISH TO DISCUSS FURTHER WITH US?
Yes
No
Submit
Should be Empty: