Two Week Checkup Form

Two Week Checkup Form
Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Today's Date *

Month Day Year
Date
Do you have any concerns about any of the following?

Eating Weight Sleeping Vision Hearing
Do you always use a rear facing car seat positioned in the back seat? *

Yes No
Do you always place your baby to sleep on his/her back in a crib or bassinet? *

Yes No
Do you know what to do if your baby is choking or stops breathing? *

Yes No
Is your water heater set at or below 120 degrees? *

Yes No
Does anyone smoke near your baby? Or in your house or car? *

No Yes
Do you have concerns regarding conflict or violence in your home? *

No Yes
Do you have concerns regarding the use of drugs or alcohol by anyone caring for your child? *

No Yes
Do you have working smoke alarms and carbon monoxide detectors in your home? *

Yes No
In the past 12 months, have you worried that food would run out before you'd have money to buy more? *

No Yes
In the past 12 months, have you run out of food and didn't have enough money to buy more? *

No Yes
Any other CONCERNS or TOPICS you would like to discuss with your doctor? *

No Yes
Should be Empty:

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