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 daily? Check all that apply.*

Does your child snore?*

Is your child potty trained?*

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 appropriate car seat or booster seat for their height and weight on every trip?*

Does your child wear a helmet while riding a scooter/bicycle/etc?*

Does your child know how to swim?*

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

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

Are there any guns/firearms in any home where your child spends time?*

If yes, have you confirmed all firearms are stored unloaded and locked 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?*

Does your child get at least 3 hours or more of physical activity daily?*

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

If yes, does the house 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?*