Name_____________
Date______________
4 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
Cooperation concerns ___yes ___no
Development
Social Emotional: ___Interaction with peers
___Imaginative play
Communication: ___Usually understandable
___Knows name, age, gender
Cognitive: ___Names 4 colors
___Draws person (3 body parts)
___Plays board/card games
Physical : ___Hops on 1 foot
___Balance on 1 foot for 3 seconds
___Builds tower (8 blocks)
___Copies a cross
___Brushes own teeth
___Dresses self
Additional comments: ____________________________________________________________
____________________________________________________________________________
