1 Year Previsit Questionnaire
To provide you and your child with the best possible care, we would like to know how things are going. Please answer all the questions. Thank you.
Patient's Name
*
First Name
Last Name
Patient's date of birth
*
-
Month
-
Day
Year
Date
Name of person filling out form
*
First Name
Last Name
Relationship to patient
*
mother
father
grandparent
foster parent
other relative
TELL US ABOUT YOUR CHILD AND FAMILY
What excites or delights you most about your child?
Does your child have special health care needs?
No
Yes
Have there been major changes lately in your child's or family's life?
No
Yes
Have any of your child's relatives developed new medical problems since your last visit?
No
Yes
Unsure
If yes or unsure, please describe:
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
No
Yes
Unsure
YOUR GROWING AND DEVELOPING CHILD
Do you have specific concerns about your child's development, learning or behavior?
No
Yes
Check off each of the tasks that your baby is able to do.
RISK ASSESSMENT
HEARING: Do you have concerns about how your child hears?
No
Yes
Unsure
HEARING: Do you have concerns about how your child speaks
No
Yes
Unsure
LEAD: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or that was renovated in the past 6 months?
No
Yes
Unsure
ORAL HEALTH: Does your child's primary water source contain fluoride?
Yes
No
Unsure
TUBERCULOSIS: Was your child or any household member born in, or has he or she traveled to, a country where tuberculosis is common (this includes countries in Africa, Latin America, and Eastern Europe)?
No
Yes
Unsure
TUBERCULOSIS: Has your child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
No
Yes
Unsure
VISION: Do you have concerns about how your child sees?
VISION: Do your child's eyes appear unusual or seem to cross?
No
Yes
Unsure
VISION: Do your child's eyelids droop or does one eyelid tend to cross?
No
Yes
Unsure
VISION: Do your child's eyelids droop or does one eyelid tend to close?
No
Yes
Unsure
VISION: Have your child's eyes ever been injured?
No
Yes
Unsure
DO YOU HAVE ANY OTHER CONCERNS YOU WITH TO DISCUSS FURTHER WITH US?
Yes
No
Submit
Should be Empty: