12 Months Well Child Visit
Patient's First & 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 the last visit?
*
No
Yes
Has there been a major change in your life recently? (Such as a change in living situation, change in daycare, move, divorce, remarriage, new job, illness, or other stressor)?
*
No
Yes
Has there been a change in your family medical history since your last visit?
*
No
Yes
Is your child in daycare?
*
No
Yes
Do you have any concerns about any of the following for your child? (Select all that apply)
Eating
Sleeping
Vision
Hearing
Growth
Do you brush your child's teeth twice daily?
*
Yes
No
Do you put sunscreen on your child when outdoors?
*
Yes
No
If your child is breastfed, do you give your child a vitamin supplement?
*
Yes
No
N/A
Does your child primary water source contain fluoride, such as public water or bottled water with fluoride?
*
Yes
No
Do you always use a rear facing car seat positioned in the back seat?
*
Yes
No
Do you avoid foods that can cause your child to choke (peanuts, hot dogs, popcorn, raw vegetables, hard candy)?
*
Yes
No
Is your child always supervised around water?
*
Yes
No
Does anyone smoke near your child? Or in your house or car?
*
No
Yes
Do you have a gun in your home?
*
No
Yes
Is your gun locked?
*
N/A
Yes
No
Do you have concerns regarding conflict or violence in your house?
*
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
Do you put your baby in the walker?
*
No
Yes
Does your child live in or regularly visits a home or childcare built before 1950?
*
No
Yes
Does your child live in or regularly visits a home or childcare built before 1978 that has been recently renovated or remodeled?
*
No
Yes
Has your child been recently exposed to anyone with TB?
*
No
Yes
Has your child been exposed to anyone with a positive TB skin test?
*
No
Yes
Was your child born in or recently traveled to a country with a high risk for TB (Asia, Middle East, Africa, Latin America)?
*
No
Yes
In the last 12 months, have you worried that food would run out before you would have money to buy more?
*
No
Yes
In the last 12 months, have you run out of food & didn't have enough to buy more?
*
No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
Submit
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