15 Month Well Child Visit

15 Month Well Child Visit
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
General Health and Nutrition
Has your child had any serious injuries or illnesses since last visit?*

NoYes
Has there been a major change in your child's life recently? (such as a change in living situation, change in daycare, move, divorce , marriage, new job, illness or other life stressors)*

NoYes
Has there been a change in your family medical history since your last visit?*

NoYes
Is your child in daycare?*

NoYes
Do you have any concerns about any of the following for your child?

EatingSleepingHearingVisionGrowth
Does your child drink out of a baby bottle?*

NoYes
Do you brush your child's teeth twice daily?*

YesNo
Has your child seen a dentist in the last 6 months?*

YesNo
Do you put sunscreen on your child when outdoors?*

YesNo
Does your child's primary water source contain fluoride, such as public water or water bottled with fluoride?*

YesNo
Does your child spend time watching screens (such as TV, tablet, computer or phone)?*

NoYes
Safety
Do you always use a rear facing car seat positioned in the back seat?*

YesNo
(Infants and toddlers should ride in a rear facing car seat until age 2, or until they reach the maximum height or weight for the seat.)
Is your child always supervised around water?*

YesNo
Have you childproofed your home?*

YesNo
Are medicines, cleaning supplies and other poisons locked up or out of reach?*

YesNo
Do you have the Poison Control Center number handy?*

YesNo
Do you avoid foods that can cause your child to choke (peanuts, hot dogs, popcorn, raw vegetables, hard candy)?*

YesNo
Does anyone smoke near your child? Or inside your house or car?*

NoYes
Do you have a gun in your home?*

NoYes
If so, is it locked?*

N/AYesNo
Do you have concerns regarding conflict or violence in your home?*

NoYes
Do you have concerns regarding the use of drugs or alcohol by anyone caring for your child?*

NoYes
Do you have working smoke alarms and carbon monoxide detectors in your home?*

YesNo
Any other CONCERNS or TOPICS you would like to discuss with your doctor?
Should be Empty:

15 Month Well Child Visit

General Health and Nutrition

Safety