9-12 Year Old Well Child Visit -Parent

9-12 Year Old Well Child Visit -Parent
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 injuries or serious illnesses since your last visit? *

No Yes
Has there been a major change in your child's life recently (such as a change in living situation, a move, divorce or marriage, new job, illness or other stressors)? *

No Yes
Do you have any concerns about your child's diet, weight or nutrition? *

No Yes
Does your child brush teeth twice daily? *

Yes No
Has your child seen a dentist in the last 6 months? *

Yes No
Does your child consistently use sunscreen while outdoors? *

Yes No
Does your child watch more than 2 hours of screen time per day (such as TV, tablet, computer, phone)? *

No Yes
Has your child used a tanning bed? *

No Yes
Safety
Does your child always wear a seat belt in the car? *

Yes No
Does your child ride in the front seat? *

No Yes
Does your child always wear a helmet while using a bike, scooter, skateboard, roller blades and skis? *

Yes No
Does your child know how to swim? *

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

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

No Yes
Has your child expressed any concerns regarding bullying? *

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

No Yes
If yes, is it locked? *

N/A Yes No
Do you have any 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 any concerns about your child's use of the internet or cell phones? *

No Yes
Have you spoken to your child about puberty, drugs, alcohol and tobacco? *

Yes No
Are you concerned that your child is using drugs, alcohol or tobacco? *

No Yes
TB (Tuberculosis) Risk
Has your child been exposed to anyone with TB 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
Family History
Do you know your child's 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 a stroke or heart problems before the age of 55? *

No Yes
Does your child have a parent with high blood cholesterol (over 240) or who is taking cholesterol medication? *

No Yes
Has your child been in trouble at school or with the law? *

No Yes
In the last 12 months, have you worried that food would run out before you had money to buy more? *

No Yes
In the last 12 months, have you run out of food and didn't have money to buy any more? *

No Yes
We recommend the below vaccines at 11-12 years old.
Please check any vaccine you have a question or concern about

TDaP (Tetanus, Diphtheria, Pertussis) Menveo (Meningococcal) HPV (Human Papilloma Virus)
Any other concerns or topics you would like to discuss with your doctor?

Pediatric Symptom 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 describes your child.

*

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 sit 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

PSC-17: I
PSC-17: A
PSC-17: E
Total
Should be Empty:

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