Name_____________
Date______________
3 years
Parental concerns this visit: __________________________________________________
____________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Parents working outside home ____mother ____father
Child Care ____yes ____no Type______________________________________
Preschool ____yes ____no _______________________
Changes since last visit _________________________________________________
Diet
5 servings of fruit/vegetable ___yes ___no
Limited sweetened liquids ___yes ___no
Vitamins/Supplements ______________________________________
Diet Concerns ___yes ___no
Diet comments ____________________________________________________________
Bowel/Bladder
Stool Concerns ____yes ____no
Stool Consistency ____hard ____soft
Urination Concerns ____yes ____no
Toilet training ___yes ___ in process ___no
Sleep
Sleep concerns ___yes ____no
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Physical Activity Play time (60m/d) ___yes ___no
Screen time (<2hr/d) ___yes ___no
Parent-child Interaction
Communication concerns ___yes ___no
Offer choices ___yes ___no
Cooperation concerns ___yes ___no
Development
Social Emotional: ___Self care skills
___Imaginative play
Communication: ___2-3 sentences
___Usually understandable
___Names a friend
Cognitive: ___Names objects
___Knows if boy or girl
Physical : ___Build tower (6-8 blocks)
___Stands on 1 foot
___Throws ball overhand
___Walks upstairs alternating feet
___Copies circle
___Draws person (2 body parts)
___Toilet trained during day
Additional comments: __________________________________________________________
___________________________________________________________________
