3-5 Year Old Well Child Visit
Patient's Name
*
First Name
Last Name
Patient Date of Birth
*
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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 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, remarriage, new job, illness, or other stressor)?
*
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
Has your child seen a dentist in the past 6 months?
*
Yes
No
Does your child's primary water source contain fluoride such as public water or bottled water with fluoride?
*
Yes
No
Do you put sunscreen on your child when outdoors?
*
Yes
No
Does your child watch more than 1 hour of screen time per day (Such as TV, tablet, computer, or phone)?
*
No
Yes
Do you always use a car seat (or booster seat) positioned in the back? Children should use a car seat with a harness as long as possible
*
Yes
No
Is your child always supervised around water?
*
Yes
No
Are your cleaning supplies, poisons, and medications locked?
*
Yes
No
Do you have the poison control number handy?
*
Yes
No
Does your child wear a helmet while riding a bike or in a bike carrier?
*
Yes
No
Do you have working smoke alarms and carbon monoxide detectors in your home?
*
Yes
No
Does anyone smoke near your child? Or inside the house or car?
*
No
Yes
Do you have a gun in your house?
*
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 alcohol by anyone caring for your child?
*
No
Yes
Has your child been exposed to anyone with TB (Tuberculosis) disease or a positive TB skin test?
*
No
Yes
Was your child born in a country with a high risk for TB (Asia, Middle East, Africa, Latin America)?
*
No
Yes
Has your child lived in or recently traveled to a country with a high risk for TB?
*
No
Yes
Do you know your family medical history?
*
Yes
No
Has there been a change in your family medical history since your last visit?
*
No
Yes
Does your child have parents or grandparents who have had stroke or heart problems before age 55?
*
No
Yes
Does your child have a parent with high cholesterol (over 240) or is taking cholesterol medication?
*
No
Yes
In the last 12 months, have you worried that food would run out before you got enough money to buy more?
*
No
Yes
In the last 12 months, have you ran 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?
Submit
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