6-8 Year Old Well Child Visit
Patient's Name
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First Name
Last Name
Patients Date of Birth (mm/dd/yyyy)
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
General Health and Nutrition
Has your child had any injuries or serious illnesses since the last visit?
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No
Yes
Has there been a major change in your child's life recently (such as change in living situation, change in daycare, move, divorce, remarriage, new job, illness, or other stressor)?
*
No
Yes
Do you have any concerns about your child's diet, weight, or nutrition?
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No
Yes
Does your child brush their teeth twice daily?
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Yes
No
Has your child seen a dentist in the past 6 months?
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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
Do you put sunscreen on your child when outdoors?
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Yes
No
Does your child watch more than 2 hours of screen time per day (such as TV, tablet, computer, phone)?
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No
Yes
Safety
Does your child always ride in a booster seat (or seat belt if appropriate) in the backseat? (Booster seats should be used until a child reaches 4 feet 9 inches in height)
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Yes
No
Does your child always wear a helmet while using a bike, scooter, skateboard, roller skates, and skis?
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Yes
No
Does your child know how to swim?
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Yes
No
Is your always supervised near water (pools,lakes)?
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Yes
No
Have you talked to your child about stranger safety?
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Yes
No
Does your child know his/her address and phone number?
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Yes
No
Has your child expressed any concerns regarding bullying?
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No
Yes
Does anyone smoke near your child, or inside your house or car?
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No
Yes
Do you have a gun inside your home?
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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?
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No
Yes
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 house?
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Yes
No
TB (Tuberculosis) Risk
Has your child been exposed to anyone with TB (tuberculosis) disease or a positive TB test?
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No
Yes
Was your child born in a country with a high risk for TB (Asia, Middle East, Africa, Latin America)?
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No
Yes
Has your child lived in or recently traveled to a country with a high risk for TB?
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No
Yes
Family History
Do you know your child's family medical history?
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Yes
No
Has there been a change in your family medical history since your last visit?
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No
Yes
Does your child have parents or grandparents who have had a stroke or heart problems before age 55?
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No
Yes
Does your child have a parent with high blood cholesterol (over 240), or who is taking cholesterol medication?
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No
Yes
In the last 12 months, have you worried that food would run out before you got enough money to buy more?
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No
Yes
In the last 12 months, have you run out of food & didn't have enough money to buy more?
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No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
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Pediatric System Checklist (PSC-17)
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions, or learning, you can help your child get the best care possible by answering these questions. Please indicate how each of these statements best describe your child.
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Never
Sometimes
Often
1. Feels sad, unhappy
2. Feels hopeless
3. Is down on self
4. Worries a lot
5. Seems to be having less fun
6. Fidgety, unable to set still
7. Daydreams too much
8. Distracted easily
9. Has trouble concentrating
10. Acts as if driven by a motor
11. Fights with other children
12. Does not listen to rules
13. Does not understand other people's feelings
14 Teases others
15. Blames others for his/her trouble
16. Refuses to share
17. Takes things that do not belong to him/her
Submit
PSC-17: I
PSC-17: A
PSC-17: E
PSC-17: Total
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