Illini Pediatrics LLC, DBA Ideal Pediatrics

Child's Full Name: * Child's Date of Birth * Do you have an appointment scheduled? *

15 month Developmental

Please read each questions carefully and check the box that best describes your child's behavior. Check the box if this behavior is a concern for you.

1. Does your child look at you when you talk to him? 2. When you leave, does your child remain upset and cry for more than an hour? 3. Does your child laugh or smile when you play with her? 4. Does your child look for you when a stranger approaches? 5. Is your child's body relaxed? 6. Does your child like to be hugged or cuddled? 7. When upset, can your child calm down within 15 minutes? 8. Does your child stiffen and arch his back when picked up? 9. Does your child cry, scream, or have tantrums for long periods of time? 10. Is your child interested in things around her, such as people, toys, and foods? 11. Does your child do things over and over and can't seem to stop? Examples are rocking, hand flapping, spinning or other? Please explain if other: 12. Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items, or other? If other please explain here: 13. Does your child have trouble falling asleep at naptime or at night? 14. Do you and your child enjoy mealtimes together? 15. Does your child sleep at least 10 hours in a 24-hour period? 16. Does your baby have trouble falling asleep at naptime or at night? 17. Does your baby sleep at least 10 hours in a 24-hour period? 18. Does your child let you know how she is feeling with gestures or words? For example, doe she let you know when she is hungry, hurt, or tired? 19. Does your child follow simple directions? For example, does he sit down when asked? 20. Does your child like to play near or be with family members and friends? 21. Does your child check to make sure you are near when exploring new places, such as a park or a friend's home? 22. Does your child like to hear stories or sing songs? 23. Does your child hurt herself on purpose? 24. Does your child like to be around other children? 25. Does your child try to hurt other children, adults, or animals (for example, by kicking or biting)? 26. Has anyone expressed concerns about your child's behaviors? If you checked "sometimes" or "most of the time," please explain: 27. Do you have concerns about your child's eating or sleeping behaviors? If so, please explain: 28. Is there anything that worries you about your child? If so, please explain: 29. What things do you enjoy most about your child?

Bright Futures- How is your child doing?

For us to provide you and your child with the best possible health care, we would like to know how things are going. Please answer all of the questions. Thank you.

We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.

Talking and Feeling A Good Night's Sleep Temper Tantrums and Discipline Healthy Teeth Safety

Questions about your child

Have any of your child's relatives developed new medical problems since your last visit? If yes, please describe: Do you have concerns about how your child hears? Do you have any concerns about how your child speaks? Do you have concerns about how your child sees? Does your child hold objects close when trying to focus? Do your child's eyes appear unusual or seem to cross, drift, or be lazy? Do your child's eyelids droop or does one eyelid tend to close? Have your child's eyes ever been injured? Does your child have any special health care needs? If yes, please describe: Have there been any major changes in your family lately? Check off each of the tasks that your child is able to do Lists what words your child says:

Lead Risk Assessment

Any child ages less than 72 months with a positive response to any of the following questions is at risk and must receive a blood lead test immediately

Have siblings or playmates with lead poisoning? Live in or regularly visit a house or day care built before 1950? Reside in or visit a house built before 1978 with chipping paint or remodeling within the last 6 months? **Mouth or eat non-food items (pica)? Play in bare soil or reside in a lead smelting area? Reside with an individual that works with or has hobbies using lead? Receive unusual medicines or folk remedies? Between 12 & 72 months, and has never received a blood lead test? Live in an area of the state at high-risk for lead poisoning? (list published annually)

TB Risk Assessment

1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray? If yes, name of symptoms: 2. In the last 15 months, has the child lived with or spent time with someone who has been sick with TB? 3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East? If yes, what country: 4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month? If yes, what country: 5. Have any member of the child's household come to the United States from another country? If yes, what country: 6. Is the child exposed to a person who: 7. Is the child/teen in jail or ever been in jail? 8. does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? If yes, name disease or medication:

If yes, to any of the above, the child has and increased risk of TB infection and should have a TST/IGRA. All children with a positive TST/IGRA result must have a medical evaluation, including a chest X-ray. Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of active TB. If testing was done, please attach or enter results on next page.