Overview

Print this page and fill in the information if you are bringing your child in for an appointment.

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.

What medicines (including prescription, over-the-counter, herbs, and natural health products) has my child taken since our last visit?

Does my child have any new allergies to medicines, foods, or other substances? Yes ___ No ___ If yes, fill in the following information.

Do I have any concerns for my child in any of the following areas? If yes, describe the problem.

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.