Alert

Regular Checkup for a Child

Topic 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

  • Bring your child's immunization record to the appointment. If you do not have a record, ask your doctor for one.
  • Bring a list of all medicines your child is taking, or bring the medicines with you to the appointment.
  • Ask about normal growth and development milestones to look for in your child.

Credits

Current as of: August 22, 2019

Author: Healthwise Staff
Medical Review: John Pope, MD, MPH - Pediatrics
Kathleen Romito, MD - Family Medicine
Louis Pellegrino, MD - Developmental Pediatrics
Susan C. Kim, MD - Pediatrics

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