9 Month Well Child Visit
Patient's Full Name
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Patient's Date of Birth
*
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Month
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Day
Year
Date
Today's Date
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Month
-
Day
Year
Date
Has there been any injuries or serious illnesses since the 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?
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No
Yes
Has there been a change in your family medical history since the last visit?
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No
Yes
Is your child in daycare?
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No
Yes
Do you have any concerns about any of the following for your child? (Select all that apply)
Eating
Sleeping
Vision
Hearing
Growth
Does your child fall asleep while nursing or while drinking a bottle?
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No
Yes
If your child is breastfed, do your give your child a vitamin supplement?
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N/A
Yes
No
Does your child's primary water source contain fluoride, such as public water or bottled water with fluoride?
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Yes
No
Back
Next
Do you always use a rear facing car seat positioned in the back? (Infants should ride in a rear facing car seat until the age of 2 or until they reach the maximum height and weight for the seat.)
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Yes
No
Do you know what to do if your child is choking or stops breathing?
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Yes
No
Is your child always supervised around water?
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Yes
No
Have you childproofed your home? (Poisons/ medications out of reach, cabinet latches, gates on stairs, cords/outlet covers)
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Yes
No
Do you have the Poison Control Center number?
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Yes
No
Do you have a gun in your home?
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No
Yes
If you have a gun, is it locked?
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N/A
Yes
No
Do you have concerns regarding conflict or violence in your home?
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No
Yes
Back
Next
Do you have concerns regarding the use of drugs or alcohol by anyone caring for your child?
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No
Yes
Do you have working smoke alarms and carbon monoxide detectors in your home?
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Yes
No
Do you put your baby in a walker?
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No
Yes
Do you put sunscreen on your child when outdoors?
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Yes
No
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
Submit
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