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:
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 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
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
Review of Systems
Mark anything that has occurred in the past week or mark ‘none of the following’.
CONSTITUTIONAL:
O sleep problems
O none of the following O weight loss
O sweating
O decreased energy
CARDIOLOGY:
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
DERMATOLOGY:
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
MUSCULOSKELETAL:
RESPIRATORY:
UROLOGY:
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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