Well Child Check - Children Age 0-4 Patient`s name: DOB: ______

Well Child Check - Children Age 0-4
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 O No
During the day: O Day care
O Early Education
O At home O At a relative’s home
Diet: O Breast
O Bottle
O Both
O Balanced, Solid foods
Problems with Bladder or Bowels?:
O Yes
O No
Sleeping habits: O Sleeps in own bed O Crib/bassinet
O Co-sleep with parents
How many hours of TV or computer time daily?
O None O 1 O 2 O 3 O 4 O 5+
Social interactions:
O Play group O Siblings O Early Education
Would you like information about car seat safety?
O Yes
O No
Do you have questions about baby proofing your home?
O Yes
O No
Are there guns in the home?
O No
O Yes:
In a safe?
O Yes
O No
Current Medication(s), including vitamins, supplements/herbs – dose and quantity:
O Multivitamin
O Fluoride
O Other: __________________________________
Allergies __________________ Reaction: _______________________
Medical History: Current and/or have a history of:
O Heart Disease O Diabetes O Cancer O Asthma O Psychiatric Disorder O ADD or ADHD
O Bleeding disorder O Thyroid Disease O Kidney Disease O Bowel Disease
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 Other relatives
O Friends
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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
Review of Systems
Mark anything that has occurred in the past week or mark ‘none of the following’.
O sleep problems
O none of the following O weight loss
O sweating
O decreased energy
O none of the following
O exhaustion with eating
O eating problems
O heart defect O heart murmur
O bluish lips
EAR, NOSE AND THROAT: O none of the following O runny nose-congestion O eye discharge
O ear pain or discharge
O excessive salivating
O teething
O swollen glands
O eczema
O none of the following O rash(s)
O hair problems
O nail problems
GASTROENTEROLOGY: O none of the following O excessive or forceful spit up
O diarrhea O constipation
O blood in stool
O none of the following
O none of the following
O none of the above
O muscle weakness
O cough
O blood in urine
INFECTIOUS DISEASE: O none of the following
O recently exposed to sick contacts
O vomiting
O congestion
O wheezing
O foul smelling urine
O fevers
O recent illness
NEUROLOGY: O none of the following O doesn’t respond to voices or loud noises
O doesn’t make eye contact
O doesn’t follow objects with eyes O has seizures
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