12 month old Well Child Visit Questionnaires Patient Information Child's Name * First Name Last Name Child's Birthday * MM DD YYYY Name of Parent filling out form * First Name Last Name Today's Date * MM DD YYYY Pediatric Evaluation Developmental Survey (PEDS) Do you have any concerns about the way your child talks or makes speech sounds? * YES NO A little Comments: Do you have any concerns about how your child understands what you say? * YES NO A little Comments: Do you have any concerns about the way your child uses his/her hands or fingers to do things? * YES NO A little Comments: Do you have any concerns about the way your child uses his/her legs? * YES NO A little Comments: Do you have any concerns about the way your child behaves? * YES NO A little Comments Do you have any concerns about how your child interacts with others? * YES NO A little Comments: Do you have any concerns about how your child is learning new things to do things for him/herself? * YES NO A little Comments: Do you have any concerns about how your child is learning preschool or school skills? * YES NO A little Comments: Please list any other concerns you have about your chlid's learning, development, or behavior. Thank you! FORMS SUBMITTED.
