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?*

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

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?*

Is your child doing well in school?*

Does your child have friends at school?*

Is your child involved in after-school/extra-curricular activities?*

Does your child receive any special education services?*

Does your child live with anyone who uses tobacco or spend time in any place where people smoke?*

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

Have you talked with your child about how to get help and who to call if there is an emergency?*

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 home your child visits?*

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

Do you supervise your child's Internet use?*

Do you have rules about Internet use?*

Do you use safety filters on computers, tablets, and smartphones?*

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

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

Do you know your child's friends and their families?*

Does your child know how to get help in an emergency if you aren't there?*

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

Pubertal development: Have you talked with your child about how their body will change during puberty?*

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

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?*