Print this page and fill in the information if you are bringing your child in for an appointment.
What questions or concerns do I have about my child that I want addressed during this appointment?
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Are there any recent stresses in the family that may be affecting my child, such as death of a loved one, loss of a job, or conflicts? ______ Yes ______ No. If yes, describe the recent stresses briefly:
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Since the last appointment, has my child had any recent injury or been diagnosed with any new disease or condition? Yes ___ No ___. If yes, fill in the following information.
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Injury, condition, or disease
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Health professional who diagnosed the condition
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What was the prescribed treatment?
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What medicines (including prescription, over-the-counter, herbs, and natural health products) has my child taken since our last visit?
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Name of medicine
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What was the medicine for?
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Does my child have any new allergies to medicines, foods, or other substances? Yes ___ No ___. If yes, fill in the following information.
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Medicine or substance
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Reaction
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Do I have any concerns for my child in any of the following areas? If yes, describe the problem.
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Describe the problem |
| Sleeping |
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| Eating |
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| Bowel or bladder |
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| Speech and language |
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| Hearing |
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| Vision |
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| How my child behaves |
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| Physical growth and coordination |
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| Emotional state |
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| School or daycare |
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| Physical activity |
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Do I need any written information or instructions about my child's care, such as growth and development changes to expect?
Reminders
- Bring your child's immunization record to the appointment. If you do not have a record, ask your doctor for one.
- Bring a list of all medicines your child is taking, or bring the medicines with you to the appointment.
- Ask about normal growth and development milestones to look for in your child.