Regular Checkup for a Child
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 the recent stresses 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.
| Area of concern | 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: October 6, 2025
Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.
