Pediatric Health Assessment

Pediatric Health Assessment

(Ages 5-11) - FOR PARENT/GUARDIAN
Please answer these questions to help us get to know your child better and together we can plan the best care for your child. It is okay to skip any questions you are not comfortable answering.
General Medical Information
In the last year, have there been any changes to your child’s health or any hospital visits?

YesNo
If yes, please describe:
Has your child had an allergic reaction (bad effect) from any of the following?

No known allergiesLatexEggsPeanutsBee stingsShellfishMedicines/Drugs (please describe in the section below)Other (please describe in the section below)
If you marked allergies to Medicine, Drugs, or Other, please describe in this box.
Physical and Oral Health
1. Are there times when your family does not have enough food to eat?

YesNo
2. Does your child eat 5 servings of fruits and vegetables each day?

YesNo
3. Does your child have more than 8 oz (1 cup) of juice or soda per day?

YesNo
4. Does your child eat fast food more than once per week?

YesNo
5. Does your child exercise (play hard - like running or sports) for more than 30 minutes every day?

YesNo
6. How many hours per day does your child watch TV, go on the internet/phone or play video games?

0-11-2Greater than 2
7. Have you talked to your child about puberty?

YesNoIf no, would you like to talk about it today?
8. Does your child have trouble with constipation or bedwetting?

YesNo
9. Does your child brush teeth twice daily and floss once a day?

YesNo
10. When was their last dentist check-up?

MonthDayYear
Date
Safety and Injury Prevention
11. When riding in a car, does your child use a seatbelt or booster seat?

YesNo
12. Does your child always wear a helmet when riding a bike, skateboard, roller blades, or scooter?

YesNo
13. Does your child know how to swim?

YesNo
14. Are there guns in your home or anywhere else your child spends time?

YesNo
15. Do you have a fire and earthquake emergency plan?

YesNo
16. Do you teach your child how to be safe on the internet?

YesNo
School and Friends
17. Do you have any concerns about your child’s learning or behavior in school?

YesNo
18. Does your child have at least one friend?

YesNo
19. How much school has your child missed in the last month for any reason?

None1-3 days3 or more days
20. What does your child do after school?
Emotional Well Being
21. Who lives in your child's home?
22. Do you have any worries about you child's mood or behavior? (example - hyperactive, angry, sad, withdrawn, scared, shy, or irritable)

YesNo
23. Does your child have any problems with sleep or nightmares?

YesNo
24. Does anyone bully or pick on your child, online or at school?

YesNo
Risk Reduction/Concerns
25. Do you talk to your child about the risks of drugs, alcohol, and sexual activity?

YesNo
26. Do you have any worries about your child’s behavior?

YesNo
27. Does anyone in your child’s house smoke cigarettes?

YesNo
28. We know that what is happening in a child’s life can affect their health. Have you, your child or your family been affected by any of these in the last year? (select all that apply)

Move, deportation or evictionDivorce, break-up or separationDeath or violenceDrug or alcohol abuseThreats, abuse, or neglectPrison/JailDHS involvement/foster careMental illness (depression, anxiety, bipolar disorder, suicide attempt)Racism or discriminationNone of the above
Strengths
Check off all the items that you think are true for your child.

Our family helps and supports each other.My child likes to read.My child works hard in school, sports, or other activities.My child feels good about him or herself.My child/family is involved in my community (religious, sports, service, family, or neighborhood
My child has these healthy behaviors (like exercise, healthy eating):
Things that make me proud of my child:
Additional Concerns
Are there any other questions or concerns you would like to discuss today?
Signature

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Today's Date

MonthDayYear
Date
Should be Empty:

Pediatric Health Assessment

General Medical Information

Physical and Oral Health

Safety and Injury Prevention

School and Friends

Emotional Well Being

Risk Reduction/Concerns

Strengths

Additional Concerns