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Download 5-6 Year Health Maintenance Form
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5-6 Year Health Maintenance Form Patient Name: Circle Yes/No or answer in the space provided: New or recent health concerns? Yes No New changes or stressors in family or home? Yes No Visits to other health care providers/facilities? Yes No (move, job change, divorce, death in the family, new baby etc.) School/Play/Social Development: Does your child currently attend… (circle one if applicable) Preschool Kindergarten 1st Grade Name of school attending: Is your child… Academically successful at school? Yes No Yes No Sleep: Does your child sleep at least 9 hours at night with no night time awakenings? Yes No Elimination: Does your child stool and urinate regularly? Yes No Oral Health: Does your child have regular dental visits? Yes No Does your child brush teeth with help daily? Yes No Diet: Eat a variety of foods/well balanced diet? Yes No Are you able to put food on the table daily for your family? Yes No Does your child… Balance on one foot, hop, and skip? Tie a knot? Have a mature pencil grasp? Draw a person with a head, body, arms, and legs? Print some letters and numbers? Count to 10? Name 4 or more colors? Yes Yes Yes Yes Yes Yes Yes No No No No No No No Developing positive peer relationships? (fruits/veggies, whole grains, meat) —Turn Over Please— If you do not understand any of these questions, please ask your nurse. Reproduction is allowed with permission from Complete Children’s Health, P.C. (402) 465-5600 Revised 4/25/2017 Does anyone smoke in/out of the home or daycare? Yes No Does your child or any household member drink water from a private well? Yes No Tuberculosis Screening Questionnaire: Does your child have contact with adults with TB infection? Yes No Is child or parent from a region of the world with a high prevalence of TB? Yes No Is child frequently exposed to immunosuppressed persons, homeless people, nursing home residents, or migrant workers? Yes No Does either parent or other individual living in home work in a medically related field or have contact with institutionalized individuals or nursing home residents? Yes No Cholesterol Risk Assessment Questionnaire: Parent or Grandparent with heart disease or stroke under the age of 55? Yes No Parent or Grandparent with elevated cholesterol >240? Yes No (vacation homes, relative’s or friend’s home, daycare or school) (Regions other than the US, Canada, Australia, New Zealand, Western Europe) If you do not understand any of these questions, please ask your nurse. Reproduction is allowed with permission from Complete Children’s Health, P.C. (402) 465-5600 Revised 4/25/2017
