Child Well-Visit Questionnaire
Please complete this questionnaire to help us assess your child's health and development during their well-visit.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Guardian
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has your child had any illnesses or hospital visits since the last checkup?
*
Yes
No
Please indicate your child's progress in the following areas:
*
Rows
Not Yet
Sometimes
Always
Walking independently
1
2
3
Speaking in sentences
4
5
6
Feeding self
7
8
9
Using the toilet
10
11
12
Following simple instructions
13
14
15
How would you describe your child's nutrition?
*
Excellent
Good
Fair
Poor
How many hours does your child sleep at night on average?
*
Does your child have any behavioral or emotional concerns?
Tantrums
Difficulty with attention
Aggression
Anxiety
None
Other
Does anyone in the household smoke?
*
Yes
No
Do you have any concerns or questions about your child's health, development, or safety?
Submit Questionnaire
Should be Empty: