30 Month Old Well Child Visit
Name
*
Patient's First Name
Patient's Last Name
Patient DOB
*
-
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 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
Has there been a change in your family's medical history for 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?
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 primary water source contain fluoride, such as public water or bottled water with fluoride?
*
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 Center number handy?
*
Yes
No
Does your child wear a helmet while riding in a bike carrier?
*
Yes
No
Does anyone smoke near your child?
*
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 alcohol in your by anyone caring for your child?
*
No
Yes
Do you have working smoke alarms and carbon monoxide detectors in your home?
*
Yes
No
Any CONCERNS or TOPICS that you want to discuss with your doctor?
*
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