Name_____________
Date______________
2 years
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
Physical Activity Play time (60m/d) ___yes ___no
Screen time (<2hr/d) ___yes ___no
Development
Social Emotional: ___Copies things that you do
___Plays Pretend
___Plays alongside other children
Communication: ___When talking puts 2 words together (my book)
Cognitive: ___Names 1 picture (eg cat dog)
___Follows 2-step commands
Physical : ___Stacks small blocks (5-6)
___Kicks a ball
___Walks up and down stairs
___Throws a ball overhand
___Jumps up
___Turns book pages 1 at a time
Additional comments: ____________________________________________________________
________________________________________________________________________________
