One Month Well Child Visit
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 for your baby?
Vision
Eating
Sleeping
Weight
Hearing
If your child is breastfed, do you give your child a vitamin supplement?
*
N/A
Yes
No
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 any 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 last 12 months, have you worried that food would run out before you'd have money to buy more?
*
No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
*
No
Yes
If yes, please write them here
Submit
Should be Empty: