15-Month Pediatric Well-Child Visit Checklist Form
Complete this checklist during the 15-month pediatric well-child visit. Ensure all relevant areas are reviewed for the child's development and health.
Child's Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Caregiver/Parent Name
*
First Name
Last Name
Growth Measurements Taken
*
Weight
Length/Height
Head Circumference
Immunizations Administered Today
DTaP
Hib
PCV
MMR
Varicella
Hepatitis A
Other
Developmental Milestones Observed
Walking independently
Saying several single words
Imitates actions
Points to show interest
Nutrition and Feeding Assessment
Eating a variety of solid foods
Still breastfeeding/formula feeding
Picky eater
Other
Sleep Patterns
Sleeping through the night
Frequent night waking
Napping during the day
Other
Home Safety Reviewed
Car seat safety
Poison control
Baby-proofing
Smoke/CO alarms
Parental Questions or Concerns
Submit Checklist
Should be Empty: