Name_____________
Date______________
30 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
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
Development
Social Emotional: ___Plays pretend
___Plays with other children
Communication: ___Other people understand your child’s speech 50%
___When talking puts 2 or 4 words together
Cognitive: ___Points to 6 body parts
___Knows correct animal sounds (meow, woof)
Physical : ___Jumps up and down in place
___Puts on clothes with help
___Washes and dries hands without help
___Brushes teeth with help
Additional comments: ____________________________________________________________
________________________________________________________________________________
