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Kids Plus Pediatrics
  • Pre-Visit
  • Payments
    • Online Payments
    • Kids + Autopay
      • AutoPay Authorization
      • Kids + AutoPay FAQ
  • Patient Portal
  • Your Visit
    • New Patient Info
      • Getting Started
      • Kids + Family Guide
      • Behind the Scenes
    • Forms
    • Office Policies
      • Affordable Care Act Info
      • Financial Policy
      • Newborn Insurance Reminder
      • Non-Discrimination Policy
      • Screenings & Procedures
      • Split Family Policy
    • Patient Portal
    • Pre-Visit Questionnaires
    • Types of Visits
      • Well Visits
      • Walk-Ins
      • Virtual Visits
      • Fussy Baby
      • Dental Days
      • Adoption
      • Kids + Fit
      • Young Adult Care
    • Vaccinations
      • Vaccine Policy Statement
      • Vaccine Information Statements
      • COVID Vaccines
      • Flu Vaccines & Flu Clinics
      • HPV Vaccine: Cancer Prevention
  • Pediatrics +
    • Overview
    • Adoption
    • Behavioral Health
    • Breastfeeding
    • Concussions
    • Immunization
    • Infant Sleep
    • Nutrition & Fitness
  • Parent Resources
    • Overview
    • Blog
    • Classes
    • Doctors’ Notes
    • Podcast
    • Videos
  • Providers
  • About
    • Our Story
    • Our Mission & Vision
    • Advocacy
    • In the News
    • Kids + Jobs
    • Kids + Team
    • Kids + Teaching
    • Making Movies
    • Our Favorite Children’s Books
  • Offices
    • Overview
    • Cranberry/Seven Fields
    • Pleasant Hills
    • Squirrel Hill/Greenfield

15-Month

Child's Name(Required)
MM slash DD slash YYYY
Parent/Caregiver's Name(Required)
At what office is your appointment scheduled?(Required)
Do you have any questions, concerns, or problems you would like to discuss?(Required)
Has your child received a COVID vaccine?(Required)
Has your infant visited with other health care providers since your last visit to our office?(Required)
Are there new medical problems for the Family Medical History?(Required)
Have there been any other major changes in your family?(Required)
(Check all that apply.)
Will you need any forms completed at the time of your visit?(Required)

Nutrition

How is your baby currently feeding?(Required)
Is your child eating a balanced meal three times/day and at least three servings of dairy/day?(Required)
Do you have any concerns about your child's diet?(Required)
In the past 12 months, did you ever worry you would run out of food before you had money to buy more?(Required)
In the past 12 months, did you ever run out of food before you had money to buy more?(Required)

Voiding/Stooling

Do you have any concerns about your infant’s voiding or stooling?(Required)

Sleeping

Is your child sleeping through the night and taking one nap/day?(Required)

Development

Please check off the Developmental Milestones your infant has achieved:(Required)
Do you have any specific developmental or behavioral concerns for your child?(Required)
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Pre-Visit Questionnaires

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Contact or visit us.

Cranberry/Seven Fields
671 Castle Creek Drive
Seven Fields, PA 16046 USA

P: 724.761.2020

F: 724.778.8959

Pleasant Hills
810 Clairton Blvd.
Pittsburgh, PA 15236 USA

P: 412.466.5004

F: 412.466.7137

Squirrel Hill/Greenfield
4070 Beechwood Blvd.
Pittsburgh, PA 15217 USA

P: 412.521.6511

F: 412.521.6512

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