Name_____________
Date______________
9-10 years
9-10 Year WCC
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Family
After school care ___yes ___no school:____________________
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 ____________________________________________________________
Sleep
Sleep concerns ___yes ____no
Comments: ____________________________________________________________
Tobacco Exposure ____yes ____no
Behavior Concerns ____yes ____no
Physical Activity Play time (60m/d) ___yes ___no
Screen time (<2hr/d) ___yes ___no
School
Grade _______ Special education ___yes ___no
Social concerns ____yes ___no Social interaction _______________
Performance concerns ____yes ___no
Behavior concerns ____yes ___no
Attention concerns ____yes ___no
Homework concerns ____yes ___no
Parent/Teacher Concerns ____yes ___no
comments: ____________________________________________________
Parent child interact concerns ____yes ___no
comments: _____________________________________________________
Sib interact concerns ___yes ___no
Development
___ Eats healthy meals and snacks
___ Participates in an after school activity
___ Has friends
___ Is vigorously active for 1 hour a day
___ Has a caring family
___ Is doing well in school
___ Is getting chances to make own decisions
___ Feels good about self
___ Does an activity really well
Additional comments: ____________________________________________________________
________________________________________________________________________________
