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 always wear a properly fitting helmet while riding a bicycle, scooter, skateboard, or other wheeled toy?*

Have you taught your child how to safely cross streets and always hold an adult's hand near traffic?*

Have you discussed body safety and the importance of telling a trusted adult if someone makes them feel unsafe?*

Does your child know how to swim?*

Are there any firearms in your home?

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

Are there any firearms in homes your child visits?*

If yes, are all firearms 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?*

Do you ever struggle to put food on the table? *

Does your child’s diet include iron-rich foods such as meat, iron-fortified cereals, or beans? *

Does your child eat a vegetarian diet (does not eat red meat, pork, chicken, fish, or seafood)? *

Lead risk: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months?*

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?*

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?*