YOUR CHILD’S 18 MONTH WELL-VISIT
WHAT TO EXPECT, WHAT TO ASK
Your Name: _________________________Your Relationship to the Child:_____________________
Are there specic concerns you want to discuss today? No Yes ______________________
Have there been any MAJOR changes in your family since your last visit?
None Move Job Change Separation Divorce Death in the family
New pet Other Describe ____________________________________________
Has your child had any MAJOR illnesses and/or hospitalizations?
Have any of your child’s relatives developed new medical problems since the last visit?
Does your child have any allergies? If yes describe__________________________________
Does your child take any medications regulary? If yes, list ____________________________
_________________________________________________________________________
Do you feel like you have no one you can trust and go to for emotional support?
Do any adults who are around your child smoke (includes inside or outside the house)?
GENERAL HEALTH INFORMATION
Child lives with Parents Mother Father Stepparent Grandparent(s)
Other Describe: ________________________
Total number of adults living in home ______ Total number of children living in home ______
Who takes care of your child most days of the week? Child’s Mother Child’s Father
Other Relative (e.g. grandmother) Daycare Other Describe:________________________
In general, how well do you feel you are coping with the day-to-day demands of parenthood?
Not well at all Not very well Somewhat well Well Very well
Do you have any specic concerns about your child’s learning, development or behavior? A Lot A Little
Not at all Describe: _____________________________________________________________________
_______________________________________________________________________________________
Do you have any concerns about your child’s vision (how well your child sees)? Yes No
Do you have any concerns about your child’s hearing? Yes No
Please check each task your child is able to do right now.
Walking Drinks from a cup without spilling Speak 3 words or more
Able to take steps backwards Bend down without falling
YOUR GROWING AND DEVELOPING CHILD
Since Your Last Visit
No Yes Unsure
