5-Year Child's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Best Phone # to Contact(Required)Parent/Caregiver's Name(Required) First Last At what office is your appointment scheduled?(Required) Cranberry/Seven Fields Pleasant Hills Squirrel Hill/Greenfield Do you have any questions, concerns, or problems you would like to discuss?(Required) Yes No Has your child received a COVID vaccine?(Required) Yes No Please provide the kind, and the dates, of the COVID vaccine.(Required)Please describe(Required)Has your child visited with other health care providers since your last visit to our office?(Required) Yes No Please describe(Required)Are there new medical problems for the Family Medical History?(Required) Yes No Please describe(Required)Have there been any other major changes in your family?(Required)(Check all that apply.) Child Care Move Job Change Relationship Change Death in Family Other None Please describe(Required)Will you need any forms completed at the time of your visit?(Required) Yes No Please describe(Required)NutritionWhat is your child drinking?(Required) Milk Water Juice Is your child eating a balanced meal three times/day and at least three servings of dairy/day?(Required) Yes No Does your child eat 2 or fewer snacks per day?(Required) Yes No Do you have any concerns about your child's diet?(Required) Yes No Please describe(Required)In the past 12 months, did you ever worry you would run out of food before you had money to buy more?(Required) Yes No In the past 12 months, did you ever run out of food before you had money to buy more?(Required) Yes No Daily ActivitiesDo you have any concerns about the following?(Required) Sleeping Voiding Bowel Movements Active Playing Dentist Home Behavior None Please describe(Required)DevelopmentPlease check off all Developmental Milestones your child has completed(Required) Understand 100% speech Telling stories, singing songs and imaginative play Write name Dress and undress self Play well with other children Catch a ball, hop and jump Total bowel and bladder control Counts greater than 10 Knows address / phone number Able to draw person with 5 body parts or more Select AllDo you have any specific developmental or behavioral concerns for your child?(Required) Yes No Please describe(Required)CAPTCHA
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