Whole Child Pediatrics

3yr Developmental

Child's full name: * Child's Date of Birth Do you 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 her? 2. Does your child like to be hugged or cuddled? 3. Does your child talk and/or play with adults he knows well? 4. Does your child cling to you more than you expect? 5. When upset, can your child calm down within 15 minutes? 6. Does your child seem too friendly with strangers? 7. Can your child settle herself down after periods of exciting activity? 8. Can your child move from one activity to the next with little difficulty, such as from playtime to mealtime? 9. Does your child seem happy? 10. Is your child interested in things around him, such as people, toys, and foods? 11. Does your child do what you ask her to do? 12. Does your child seem more active the other children her age? 13. Can your child stay with activities she enjoys for at least 5 minutes (not including watching television)? 14. Do you and your child enjoy mealtimes together? 15. Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items, or other? Please explain if other: 16. Does your child sleep at least 8 hours in a 24-hour period? 17. Does your child use words to tell you what he wants or needs? 18. Does your child follow routine directions? For example, does she come to the table or help clean up her toys when asked? 19. Does your child cry, scream, or have tantrums for long periods of time? 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 hurt himself on purpose? 23. Does your child stay away from dangerous things, such as fire and moving cars? 24. Does your child destroy or damage things on purpose? 25. Does your child use words to describe her feelings and the feelings of others, such as, "I'm happy," "I don't like that," or "She's sad"? 26. Can your child name a friend? 27. Do other children like to play with your child? 28. Does your child like to play with other children? 29. Does your child try to hurt other children, adults, or animals (for example, by kicking or biting)? 30. Does your child show an interest in our knowledge of adult sexual language and activity? 31. Has anyone expressed concerns about your child's behaviors? If you checked "sometimes" or "most of the time," please explain: 32. Do you have concerns about your child's eating or sleeping behaviors? If so, please explain: 33. Is there anything that worries you about your child? If so, please explain: 34. What things do you enjoy most about your child?

Bright Futures- How is your child doing?

Do you have any concerns, questions, or problems that you would like to discuss today? Family Support Reading and Talking with Your Child Playing with Others Your Active Child Safety Have any of your child?s relatives developed new medical problems since your last visit? If yes, please describe: If yes, describe: Do you have concerns about how your child hears? Do you have concerns about how your child speaks? 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? Does your child have a dentist? Does your child's primary water source contain fluoride? Does your child have any special health care needs? If yes, describe 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? Check off each of the following that are true for your child

Lead Risk Assessment

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? 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? 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? If yes, where: 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? 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: