6 Month Well Visit
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Has your child had any injuries or serious illnesses since last visit?
*
No
Yes
Has there been a major change in your child's life recently (such as a change in living situation, change in daycare, move, divorce, remarriage, new job, illness, or other stressor?
*
No
Yes
Is your child in daycare?
*
No
Yes
Has there been a change in your family medical history since your last visit?
*
No
Yes
Do you have any concerns about any of the following for your child?
Eating
Sleeping
Vision
Hearing
Growth
If your child is breastfed, do you give your child a vitamin supplement?
*
N/A
Yes
No
Does your child's primary water source contain fluoride, such as public water or bottled water with fluoride?
*
Yes
No
Back
Next
Do you always use a rear facing carseat positioned in the back seat?
*
Yes
No
Do you know what to do if your child is choking or stops breathing?
*
Yes
No
Is your child supervised around water?
*
Yes
No
Does anyone smoke near your baby? Or in your house or car?
*
No
Yes
Do you have concerns about 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 put sunscreen on your child when outdoors?
*
Yes
No
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
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