Name_____________
Date______________
18 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 (play time, no TV) ____________________________________________________
Development
Social Emotional: ___Helps in the house
___Laughs in response to others
Communication: ___ Speaks 6 words
Cognitive: ___Knows name of favorite book ___Points to 1 body part
Physical : ___Stacks 2 small blocks ___Runs
___Walks up stairs ___Uses spoon/cup w/o spilling most of time
Additional comments: ____________________________________________________________
________________________________________________________________________________
