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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
Do I have any concerns for my child in any of the following areas? If yes, describe the problem.
Bowel or bladder
Speech and language
How my child behaves
Physical growth and
School or daycare
Do I need any written information or instructions about my child's care, such as growth and development changes to expect?
ByHealthwise StaffPrimary Medical Reviewer John Pope, MD, MPH - Pediatrics Kathleen Romito, MD - Family Medicine Louis Pellegrino, MD - Developmental Pediatrics Susan C. Kim, MD - Pediatrics
Current as ofMarch 28, 2018
Current as of:
March 28, 2018
John Pope, MD, MPH - Pediatrics & Kathleen Romito, MD - Family Medicine & Louis Pellegrino, MD - Developmental Pediatrics & Susan C. Kim, MD - Pediatrics