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.