Well Child Check - Age 5 to 11 years
Patient’s name:______________________________________ DOB:______________
Reason for visit: O Well child check
O GI issues O Sick/fever O Other: __________________
Up to date on immunizations? O Yes
O No O Own schedule
Past reactions? O Yes
Diet from all the food groups to include: O Milk/Dairy O Meat O Grains O Vegetables
Do you have regular dental check-ups every 6 months? O Yes
Grade in school? __________
Grades: O A-B
O B-C
O No
O Fruits
O No O Once a Year
O C-D
O D-F
O N/A
Have you had to repeat a grade? O Yes O No
Where do you go after school? O Home O Relative O After school activity O Other: __________
Do you play any sports/activities? O Yes: _____________
O No
How many hours of exercise do you get daily? O None O 1 O 2
Do you have friends? O Some
O Lots
O3
O4
O 5+
Do you get along with your siblings? O Yes
Do you get along with your parents? O Yes
O No
O No
How many hours of TV, computer, texting time daily? O None O 1 O 2
O3 O4
O 5+
What are your favorite things to do? ___________________________________________
Are there guns in the home?
O No
O Yes:
Do you wear Seat Belts in the car? O Yes
In a safe?
O Yes
O No
O No
Do you wear a bike helmet/safety gear? O Yes O No
Exposed to second-hand smoke? O Yes
O No
Current Medication(s), including vitamins, supplements/herbs: dose and quantity:
O Multivitamin
Allergies __________________
O Fluoride
O Other: ___________________________
Reaction: _______________________
Medical History: Current and/or have a history of:
O Heart Disease O Diabetes O Cancer O Asthma O Psychiatric disorder O Depression
O Anxiety O ADD or ADHD O Bleeding disorder O Thyroid disease O Kidney disease
O Bowel disorders O Urinary problems O Others:
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Family History:
Father
Mother
Sibling(s)
Children
Extended Family
Year of Birth
Alive
Deceased
High cholesterol
Heart disease
Hypertension
Diabetes
Cancer
Stroke
Thyroid disease
Kidney disease
Bleeding disorder
Substance abuse
Depression
Psychiatric disorder
Other
Father, step-Father, or legal guardian’s name: ____________________________________
Mother, step-Mother, or legal guardian’s name: __________________________________
Siblings name(s) and ages: ________________________________________________________
Who lives in your home, besides parents and siblings? O Grandparents O Other relatives
O Friends
Surgical History and dates:
Hospitalizations and dates:
Childhood Illnesses:
O Measles (14-day Rubeola) O Frequent colds O Pneumonia O Mumps
O Strep throat
O Tonsillitis O Rubella (3-day German measles) O Scarlet Fever O Ear Infections
O Chickenpox O Fever O Diabetes O Skin rashes O Herpes
Immunizations:
O MMR (measles, mumps, rubella) O Chickenpox O Influenza (flu) O DPT (diptheria, pertussis,
tetanus) O Tetanus O Hepatitis O Polio O Others (please list)
Social/Habit History:
Travel outside US?: O NO
O Yes = where? ______________
Do you use a smoke detector in your home?: O No
O Yes
Do you have pets?:
O No O Yes
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Review of Systems
Mark anything that has occurred in the past week or mark ‘none of the following’.
Constitutional: O None of the following O fever O weight loss O weight gain O fatigue
O loss of appetite O night sweats
Cardiology: O None of the following
O feet or hand swelling
O chest pain with exertion
O dizziness
O palpitations
Dermatology: O None of the following O rash O hair loss O skin changes O moles O sores
Endocrinology: O None of the following O excessive urination O excessive thirst
O excessive hunger O heat/cold intolerance O hair loss O hot flashes
Gastroenterology: O None of the following O nausea O vomiting O diarrhea O constipation
O blood in stool O difficulty swallowing
Hematology: O None of the following O easy bruising O bleeding gums O enlarged lymph gland
Musculoskeletal: O None of the following
O joint pain
O muscle pain
O muscle weakness
Neurology: O None of the following O headache O numbness in hands or feet
O tingling in hands or feet O fainting O seizures O trouble walking
Ophthalmology: O None of the following O visual changes
Respiratory: O None of the following O shortness of breath
O chest pain with breathing
O cough O congestion
Urology: O None of the following O painful urination O frequency O urgency O blood in urine
O incontinence O incomplete emptying
Infectious Disease: O None of the following O fever O nausea O vomiting O sick contacts
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