15 Month Well Child Visit

15 Month Well Child Visit
Patient's Name *

First Name Last Name
Patient's Date of Birth *

Month Day Year
Date
Today's Date *

Month Day Year
Date
General Health and Nutrition
Has your child had any serious injuries or 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, move, divorce , marriage, new job, illness or other life stressors) *

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 any concerns about any of the following for your child?

Eating Sleeping Hearing Vision Growth
Does your child drink out of a baby bottle? *

No Yes
Do you brush your child's teeth twice daily? *

Yes No
Has your child seen a dentist in the last 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 water bottled with fluoride? *

Yes No
Does your child spend time watching screens (such as TV, tablet, computer or phone)? *

No Yes
Safety
Do you always use a rear facing car seat positioned in the back seat? *

Yes No
(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? *

Yes No
Have you childproofed your home? *

Yes No
Are medicines, cleaning supplies and other poisons locked up or out of reach? *

Yes No
Do you have the Poison Control Center number handy? *

Yes No
Do you avoid foods that can cause your child to choke (peanuts, hot dogs, popcorn, raw vegetables, hard candy)? *

Yes No
Does anyone smoke near your child? Or inside your house or car? *

No Yes
Do you have a gun in your home? *

No Yes
If so, 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
Do you have working smoke alarms and carbon monoxide detectors in your home? *

Yes No
Any other CONCERNS or TOPICS you would like to discuss with your doctor?
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

15 Month Well Child Visit

General Health and Nutrition

Safety