Name_____________
Date______________
6 Month
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
Concerns about maternal depression ____yes ____no
Parents working outside home ____mother ____father
Child Care ____yes ____no Type______________________________________
Changes since last visit _________________________________________________
Diet
Milk ____________________________________
Type ____________________________________
Milk Amount/Time____________________________________
Solid Food Comments _______________________________________________
Source of water ______________ Vitamins/Fluoride___________
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 (tummy time, no TV) ____________________________________________________
Development
Social Emotional: ___ Shows pleasure from interactions w parents/others
Communication: ___ Uses a string of vowels (ah eh oh)
___ Beginning to recognize own name
___ Enjoys vocal turn taking
Cognitive: ___Uses visual exploration ___Beginning to use oral exploration
Physical : ___Sits briefly ____leaning forward ___Rolls over
Additional comments: ____________________________________________________________
________________________________________________________________________________
