6 Year Previsit Questionnaire

6 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 NameMiddle NameLast Name
Patient's date of birth*

MonthDayYear
Date
Name of person filling out form*

First NameLast Name
Relationship to patient*
Vaccines for Children (VFC) Eligibility Screen:
TELL US ABOUT YOUR CHILD AND FAMILY.
Does your child have special health care needs?
Have there been major changes lately in your child's or family's life?
Have any of your child's relatives developed new medical problems since your last visit?
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
YOUR GROWING AND DEVELOPING CHILD
Do you have specific concerns about your child's development, learning, or behavior?
Check off each of the tasks that your child is able to do.
RISK ASSESSMENT
ANEMIA: Does your child's diet include iron-rich foods, such as meat, iron fortified cereals, or beans?
ANEMIA: Do you ever struggle to put food on the table?
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 was renovated in the past six months?
ORAL HEALTH: Does your child have a dentist?
ORAL HEALTH: Does your child's primary water source contain fluoride?
TUBERCULOSIS: Was your child or any household member born in, or has he or she travel to, a country where tuberculosis is common (this includes countries in Africa, Asia, Latin America, and Eastern Europe)?
TUBERCULOSIS: As a child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
PEDIATRIC SYMPTOM CHECKLIST 17 (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 may help your child get the best care possible by answering these questions.

Please mark under the heading that best fits your child

	Never	Sometimes	Often
1. Fidgety, unable to sit still
2. Feels sad, unhappy
3. Daydreams too much
4. Refuses to share
5. Does not understand other people’s feelings
6. Feels hopeless
7. Has trouble concentrating
8. Fights with other children
9. Is down on him or herself
10. Blames others for his or her troubles
11. Seems to be having less fun
12. Does not listen to rules
13. Acts as if driven by a motor
14. Teases others
15. Worries a lot
16. Takes things that do not belong to him or her
17. Distracted easily

DO YOU HAVE ANY CONCERNS YOU WISH TO DISCUSS FURTHER WITH US?
Should be Empty: