11 Months Old to 2 Years

Child's Name

Date of Birth

Age

INSTRUCTIONS

In order to give your child the best care and to help identify your concerns, please answer the following questions. Find the column for your baby’s age and fill in today’s date. Answer each question by circling yes or no in the appropriate column. If you cannot answer the question, just move to the next one.

SINCE HIS/HER LAST WELL-CHILD CHECKUP HERE, HAS YOUR BABY…

1. Been seen by a doctor, clinic or other specialist besides at this office?

Yes No

2. Had any bad reactions to shots, food or medicine?

Yes No

3. Experienced any important changes for the family - moves, job loss, serious illness, family problems, new baby, etc.?

Yes No

SINCE HIS/HER LAST WELL-CHILD CHECKUP, DOES YOUR CHILD…

4. Seem to hear well?

Yes No

5. See to see well?

Yes No

6. Have eyes that cross or turn in or out?

Yes No

7. Have ear drainage or infection?

Yes No

8. Have frequent colds, runny nose, sore throat or cough?

Yes No

9. Usually breathe with his/her mouth open or snore?

Yes No

10. Ever wheeze or have trouble breathing?

Yes No

11. Have problems with stomach or bowels?

Yes No

12. Seem to have trouble urinating?

Yes No

13. Have a problem with skin rashes?

Yes No

14. Have seizures, convulsions, or blackouts?

Yes No

15. Does he/she take a bottle to bed (nap or night time)?

Yes No

16. Does he/she eat a variety of foods including representatives from each of the following: Rice, cereal, breads, or pasta? Fruits and vegetables? Milk, cheese, yogurt, and meats

Yes No

17. Do you brush/clean your baby’s teeth/gums daily?

Yes No

18. Are you concerned about his/her behavior in any way?

Yes No

19. Is he/she generally happy and pleasant to be with?

Yes No

20. Is he/she a discipline problem?

Yes No

21. Have you started toilet training?

Yes No

22. Do you have a reliable person who can help you care for your baby when you need to go out?

Yes No

23. Can you estimate how many hours a week your child is in daycare/ nursery or with a sitter?

Yes No

24. When you take your baby in the car, do you always use a safe cars seat that is firmly held down by seatbelts?

Yes No

25. Have you baby-proofed the house yet? (poison control number by the phone, stair gates, smoke alarms, plug covers, cabinet and drawer latches, guns locked and stored away from ammunition, water temperature <120 degrees, etc.)

Yes No

DOES YOUR BABY DO THESE THINGS YET?

Pull up to a standing position?

Yes No

Walk holding on to furniture?

Yes No

Use Mama or Dada correctly?

Yes No

Wave bye-bye?

Yes No

Walk alone? (For 14 months and up)

Yes No

Drink from a cup? (For 14 months and up)

Yes No

Say three or more words? (For 14 months and up)

Yes No

Understand simple commands like… “Get the ball”? (For 14 months and up)

Yes No

Correctly point to one or more parts of his body when asked (where is your nose)? (For 18 months and up)

Yes No

Use a spoon and cup? (For 18 months and up)

Yes No

Put two words together (such as - “Go bye-bye” or “Want Ball”, etc.)? (For 18 months and up)

Yes No

Go up and down stairs one at a time? (For 2 years and up)

Yes No

Kick a ball? (For 2 years and up)

Yes No

Say at least twenty words? (For 2 years and up)

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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