UPDOX - PATIENT PORTAL

Patients name * Patients DOB * Accompanied by: * Relationship to Patient * Allergies Present concerns/complaints

DAILY LIVING

How many days a week does your child eat breakfast? How many fruits and vegetables does your child eat in a day? How many juice,soda, or sweetened drinks does your child drink in a day? How many meals each week does your family eat at hometogether? How much time (outside of school and work) does your child spend watching a screen (TV, computer,etc.) How many hours a day is your child physically active (walking,running,playing,etc?) How many hours of sleep does your child get each night? Milk - Whole or 2% and how many ounces a day? Meals how many servings each day of: Cereal, Fruit,Veggies, Meat Any access to weapons? Any stressful situations in the household? Any smoking in the household / care givers Is seat belt used at all times? Home have smoke alarms? Describe after school activities Describe any personality or behavior problems Describe work/day care situation Has household chores? Have allowances? How many friends does your child have? When was the last dental exam? School performance - grade level? Grade in classes? Who all lives in the home? Electronic Signature of Guarantor/Guardian * Name and DOB of Guardian completing form * Today's date *