Patient date of birth*

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

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

Do you have any concerns about your child’s eating, nutrition, or weight?*

Do you have any concerns about your child’s sleep, including trouble falling or staying asleep, snoring, or daytime sleepiness?*

Any urinary concerns?*

Any stomach or bowel movement concerns?*

Is your child doing well in 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?*

Do any of your child's friends smoke, use or vape e-cigarettes, drink alcohol or beer, or use drugs?*

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?*

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

Are there any firearms in your home OR 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 and have safety rules or parental controls in place?*

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?*

Has your child started showing signs of 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?*