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Regular Checkup for a Child

Table of Contents


Overview

Print this page and fill in the information if you are bringing your child in for an appointment.

What questions or concerns do I have about my child that I want addressed during this appointment?




Are there any recent stresses in the family that may be affecting my child, such as death of a loved one, loss of a job, or conflicts? Yes ___ No ___ If yes, describe briefly:


Since the last appointment, has my child had any recent injury or been diagnosed with any new disease or condition? Yes ___ No ___ If yes, fill in the following information.

Injury, condition, or disease

Health professional who diagnosed the condition

What was the prescribed treatment?







What medicines (including prescription, over-the-counter, herbs, and natural health products) has my child taken since our last visit?

Name of medicine

What was the medicine for?







Does my child have any new allergies to medicines, foods, or other substances? Yes ___ No ___ If yes, fill in the following information.

Medicine or substance

Reaction





Do I have any concerns for my child in any of the following areas? If yes, describe the problem.

Sleeping


Eating


Bowel or bladder


Speech and language


Hearing


Vision


How my child behaves


Physical growth and

coordination


Emotional state


School or daycare


Physical activity


Do I need any written information or instructions about my child's care, such as growth and development changes to expect?

Reminders


Credits for Regular Checkup for a Child

Current as of: October 24, 2023

Author: Healthwise Staff (https://www.healthwise.org/specialpages/legal/abouthw/en)
Clinical Review Board (https://www.healthwise.org/specialpages/legal/abouthw/en)
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.


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