6 Year Well Visit Parent Questionnaire

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?*

Does your child have trouble going to sleep or wake up during the night?*

Any urinary concerns?*

Any stomach or bowel movement concerns?*

Is your child using fluoride toothpaste?*

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

Do you have any concerns about your child's school experience?*

Does your child receive any special education services?*

Is your child riding in the appropriate 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?*

Does your child know street safety habits, such as stopping at the curb, looking both ways, and never crossing the street without a grown-up?*

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 OR in any homes your child visits?*

If yes, have you confirmed 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?*

Have you taught your child that it is never OK for an adult to tell a child to keep secrets from her parents?*

Does your child know that it is never OK for an older child or an adult to ask to see his private parts?*

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

Anemia risk: Does your child have a diet low in iron-rich foods, or do you ever struggle to put enough food on the table?*

TB risk: Has your child had close contact with someone with TB, 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?*