|
Interval History
• • •
|
Parental Concerns
• • •
|
|
Parental concerns comments
|
Medication Record Reviewed
|
|
Has Dental Home
|
|
|
Family history changes since last visit?
|
Changes comments
|
|
Problems/Illness changes since last visit?
|
Changes comments
|
|
Nutrition
• • •
|
Nutrition Comments
|
|
Drinks water
|
Type of water
|
|
Milk Type
|
Ounces milk per day
|
|
Drinks juice
|
Ounces of Juice per day
|
|
Vitamins
|
Vitamins Type
• • •
|
|
Sleep Normal
|
Sleep Comments
|
|
Behavior/Temperament Normal
|
Behavior Comments
|
|
Play Time 60 min/day
|
Activity Comments
|
|
Screen Time <2 hours/day
|
Screen Time Comments
|
|
Social/Family changes since last
|
Changes Comments
|
|
Child Care?
|
Childcare Type
• • •
|
|
Dyslipidemia Risk Assessment
• • •
|
Speech/Hearing Risk
• • •
|
|
Vision Screening
• • •
|
Anemia Risk Assessment
• • •
|
|
Lead Risk
|
|
|
Structured Developmental Screen
|
Developmental Screen Type
• • •
|
|
Passed Developmental Screen
|
Autism Screen Used
|
|
Autism Screen Type
• • •
|
Passed Autism Screen
|
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
|
Anticip. Guidance - School Readiness
• • •
|
Anticip. Guidance - Personal Habits
• • •
|
|
Anticip. Guidance - TV Viewing
• • •
|
Anticip. Guidance - Family
• • •
|
|
Anticip. Guidance - Safety
• • •
|
Vaccines Discussed
|
|
Vaccines up to date
|
Influenza Vaccine
|
|
Additional Information
|
|
