Name_____________
Date______________
15 months
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Parents working outside home ____mother ____father
Child Care ____yes ____no Type______________________________________
Changes since last visit _________________________________________________
Diet
Nutrition: ___Breast ___Bottle ___Cup
Milk ______________ Ounces per day ___________
Source of water ______________ Vitamins/Fluoride___________
Juice Amount___________________
Diet Concerns ___yes ___no
Diet comments ____________________________________________________________
Bowel/Bladder
Stool Concerns ____yes ____no
Stool Consistency ____hard ____soft
Urination Concerns ____yes ____no
Sleep
Back sleeping ____yes ____no
Location ____co-sleep ____crib ____co-sleep & crib
Duration ____ < 3 hrs ____ 3-6 hrs ____ > 6 hrs
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Activity (playtime, no TV) ____________________________________________________
Development
Social Emotional: ___Tries to do what you do
___Helps in the house
___Listens to a story
Communication: ___ Speaks 2-3 words
___ Brings toys over to show you
Cognitive: ___Scribbles ___Follows simple commands
Physical : ___Bends down without falling ____Walks well
___Puts block in a cup ___Drinks from a cup with very little spilling
Additional comments: ____________________________________________________________
________________________________________________________________________________
