Pediatric Wellness Visit Screening
Patient Information
Child's Name
Date of Birth
Parent/Guardian Name
Visit Date
Growth Parameters
Height
Weight
Head Circumference
BMI
Developmental Screening
Any developmental concerns?
No
Yes
If yes, details
Social History
Living situation
Tobacco smoke exposure?
No
Yes
Screening Questions
Nutrition concerns
Sleep concerns
Behavioral concerns
Vision or hearing concerns
School/Daycare issues
Physical Exam Notes
Plan/Recommendations