Well Child Check - Age 5 to 11 years Patient`s name: DOB: Reason

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 No
O Fruits
O No O Once a Year
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
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:
Page 1 of 3
Family History:
Extended Family
Year of Birth
High cholesterol
Heart disease
Thyroid disease
Kidney disease
Bleeding disorder
Substance abuse
Psychiatric disorder
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
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
Page 2 of 3
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
Page 3 of 3
Related flashcards
Viral diseases

35 Cards

Create flashcards