Patient date of birth*

Do you have any concerns you’d like to discuss today?*

Have any of your child's relatives developed new medical problems since their last physical?*

Do you have any concerns about your child’s eating, nutrition, or weight?*

Do you have any concerns about your child’s sleep, including trouble falling or staying asleep, snoring, or daytime sleepiness?*

Any urinary concerns?*

Any stomach or bowel movement concerns?*

Is your child doing well in school?*

Does your child receive any special education services?*

Is there anyone in your child's life whose alcohol or drug use concerns you?*

Are there any firearms in your home OR any home your child visits?*

If yes, have you confirmed all firearms stored unloaded and locked with ammunition stored separately and locked?

Does your child get at least 1 hour or more of physical activity daily?*

Has your child started showing signs of puberty?*

Anemia risk: Does your child have a diet low in iron-rich foods (such as meat, iron-fortified cereals, or beans), limited access to food, OR—if menstruating—heavy or prolonged periods?*

TB risk: Has your child been in close contact with someone with tuberculosis, or lived in/traveled to a country where TB is common, or is your child infected with HIV?*