2 Year Old Well Child Visit
Patient's Full Name
Patient's DOB
*
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Month
-
Day
Year
Date
Today's Date
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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 concerns about any of the following for your child?
Eating
Sleeping
Vision
Hearing
Growth
Does your child drink out of a baby bottle or use a pacifier?
*
No
Yes
Do you brush your child's teeth twice daily?
*
Yes
No
Has your child seen a dentist in the past 6 months?
*
Yes
No
Do you put sunscreen on your child when outdoors?
*
Yes
No
Does your child's water source contain fluoride, such as public water or bottled water with flouride?
*
Yes
No
Does your child watch more than 1 hour of screen time per day? (such as TV, tablet, computer, phone)?
*
No
Yes
Do you always use a car seat (5 point harness) positioned in the back seat?
*
Yes
No
Is your child always supervised around water (pools, lakes)?
*
Yes
No
Have you childproofed your home?
*
Yes
No
Do you have the Poison Control number handy?
*
Yes
No
Does your child wear a helmet while riding in a bike carrier?
*
Yes
No
Does anyone smoke near your child, or inside your house?
*
No
Yes
Do you have a gun in your home?
*
No
Yes
If you have a gun, is it locked?
*
N/A
Yes
No
Do you have concerns regarding conflict or violence in your home?
*
No
Yes
Do you have concerns regarding the use of drugs or violence in your home?
*
No
Yes
Do you have working smoke alarms and carbon monoxide detectors in your home?
*
Yes
No
Does your child live in or regularly visit a home or childcare built before 1950?
*
No
Yes
Does your child live in or regularly visit a childcare built before 1978 that has been recently renovated or remodeled?
*
No
Yes
Has your child been exposed to anyone with TB disease or 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 got money to buy more?
*
No
Yes
In the last 12 months, have you run out of food & didn't have enough money to buy more?
*
No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
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