Patient date of birth*

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

Any concerns with your child's behavior, learning, speech, hearing, vision, or interactions with others?*

What does your child eat/drink regularly? Check all that apply.*

Does your child snore?*

Is your child interested in potty training?*

Any urinary concerns?*

Any stomach or bowel movement concerns?*

Is your child using fluoride toothpaste?*

Social. Please select all your child is NOT YET able to do:*

Language. Please select all your child is NOT YET able to do:*

Cognitive. Please select all your child is NOT YET able to do:*

Motor. Please select all your child is NOT YET able to do:*

Is your child riding in the correct car seat for their height and weight every trip?*

Are all medications, cleaning products, and other potentially poisonous substances stored locked or out of your child's reach?*

Does your child wear a properly fitting helmet when riding a tricycle, scooter, bicycle, or other wheeled toys?*

Is your child always supervised around water (bathtub, pool, lake, beach, etc.) Supervision means your child is always within arm's reach of a responsible adult or wearing a properly fitted, U.S. Coast Guard-approved life jacket when appropriate. *

Do you have any guns/firearms in your home?*

If answered yes, are all firearms stored unloaded and locked away with ammunition stored separately and locked?

Does your child visit any homes that have guns/firearms in them?*

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

Does your home have working smoke detectors and carbon monoxide detectors (if applicable)?*

Do you supervise your child's screen time content?*

Do you supervise your child's screen time content?*

Does your child live in or regularly visit a house, daycare center, or preschool built before 1978? *

If yes, does the house or facility have chipping or peeling paint or recent, ongoing or planned renovation or remodeling?

Have any of your children or their playmates had lead poisoning? *

Does your child often come in contact with an adult who works with lead? (Examples: construction, welding, pottery or other trades practiced in your community) *

Do you give your child home or folk remedies that may contain lead? *

Anemia risk: Does your child have a diet low in iron-rich foods, drink more than ~24 oz of cow’s milk daily, or have another risk for iron deficiency/anemia? *

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

Dyslipidemia risk: Does a parent, grandparent, aunt/uncle, or sibling have high cholesterol OR a history of heart attack, stroke, or other cardiovascular disease before age 55? *