Whole Child Pediatrics

24 month Developmental

Child's Full name: * Child's Date of Birth Does your child have an appointment scheduled? *

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. Does your child seem too friendly with strangers? 3. Does your child laugh or smile when you play with her? 4. Is your child's body relaxed? 5. When you leave, does your child remain upset and cry fro more than an hour? 6. Does your child greet or say hello to familiar adults? 7. Does your child like to be hugged or cuddled? 8. When upset, can your child calm down within 15 minutes? 9. Does your child stiffen and arch his back when picked up? 10. Is your child interested in things around her, such as people, toys, and foods? 11. Does your child cry, scream, or have tantrums for long periods of time? 12. Do you and your child enjoy mealtimes together? 13. Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items, or other? Please explain if other: 14. Does your child sleep at least 10 hours in a 24-hour period? 15. When you point at something, does your child look in the directions you are pointing? 16. Does your child have trouble falling asleep at naptime or at night? 17. Does your child get constipated or have diarrhea? 18. Does your child follow simple directions? For example, does he sit down when asked? 19. Does your child let you know how she is feeling with gestures or words? For example, does she let you know when she is hungry, hurt, or tired? 20. Does your child check to make sure you are near when exploring new places, such as a park or a friend's home? 21. Does your child do things over and over and can't seem to stop? Examples are rocking, hand flapping, spinning or other? If other please explain here: 22. Does your child like to hear stories or sing songs? 23. Does your child hurt himself 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?

What would you like to talk about today?

Your Talking Child How Your Child Behaves Toilet Training Your Child and TV Safety

Questions About Your Child

Have any of your child?s relatives developed new medical problems since your last visit? If yes, please describe: If yes, describe: Does your child have parents or grandparents who have had a stroke or heart problem before age 55? Does your child have a parent with elevated blood cholesterol (240 mg/dL or higher) or who is taking cholesterol medication? Do you ever struggle to put food on the table? Does your child?s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? Do you have concerns about how your child hears? Do you have 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 a dentist? Does your child's primary water source contain fluoride? Does your child have any special health care needs? Have there been any major changes in your family lately? Does your child live with anyone who uses tobacco or spend time in any place where people smoke?

Lead Screening

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 Screening

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 symptoms 2. In the last 2 years, 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? 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? 5. Have any member of the child's household come to the United States from another country? 6. Is the child exposed to a person who: 8. does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? If yes, name of disease or medication:

MCHAT

1. Does your child enjoy being swung, bounced on your knee, etc.? 2. Does your child take an interest in other children? 3. Does your child like climbing on things, such as up stairs? 4. Does your child enjoy playing peek-a-boo/hide-and-seek? 5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or pretend other things? 6. Does your child ever use his/her index finger to point, to ask for something? 7. Does your child ever use his/her index finger to point, to indicate interest in something? 8. Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them? 9. Does your child ever bring objects over to you (parent) to show you something? 10. Does your child look you in the eye for more than a second or two? 11. Does your child ever seem oversensitive to noise (e.g. plugging ears) 12. Does your child smile in response to your face or your smile? 13. Does your child imitate you? (e.g., you make a face-will your child imitate it?) 14. Does you child respond to his/her name when you call? 15. If you point at a toy across the room, does your child look at it? 16. Does your child walk? 17. Does your child look at things you are looking at? 18. Does your child make unusual finger movements near his/her face? 19. Does your child try to attract your attention to his/her own activity? 20. Have you ever wondered if your child is deaf? 21. Does your child understand what people say? 22. Does your child understand sometimes stare at nothing or wander with no purpose? 23. Does your child look at your face to check your reaction when faced with something unfamiliar?