36 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. Children's with Special Health Care Needs (CSHCN) Assessment 1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? * Example: Asthma inhalers, allergy medicines, heart medications, seizure medications, stomach medicines for acid, birth control, antidepressants, ADHD medications Yes -> Go to Question 1a No -> Go to Question 2 1a. Is this because of ANY medical, behavioral or other health condition? Asthma, nasal allergies, heart conditions, seizures, reflux, problems with menstruation cycle, depression, anxiety, ADHD Yes -> Go to Question 1b No -> Go to Question 2 1b. Is this a condition that has lasted or is expected to last for at least 12 months? YES NO 2. Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age? * Head Start program, sees a specialist, speech / occupational / physical therapy, sees a psychologists or psychiatrist Yes -> Go to Question 2a No -> Go to Question 3 2a. Is this because of ANY medical, behavioral or other health condition? Developmental delay such as speech delay, sees ENT for tonsils or ear problems, sees cardiology for heart problems, sees an allergiest for allergy problems, etc, depression, ADHD, muslce problems, eating problems, stomach problems Yes -> Go to Question 2b No ¤-> Go to Question 3 2b. Is this a condition that has lasted or is expected to last for at least 12 months? YES NO 3. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do? * Example: Autism, speech delayed child can't express themselves the same way compared to other children, child ADHD struggles at school Yes, go to questions 3a No, go to question 4 3a. Is this because of ANY medical, behavioral or other health condition? Yes, go to questions 3b No, go to question 4 3b. Is this a condition that has lasted or is expected to last for at least 12 months? YES NO 4. Does your child need or get special therapy, such as physical, occupational or speech therapy? * Head start program, special education classes, speech/OT/PT services Yes, go to question 4a No, go to question 5 4a. Is this because of ANY medical, behavioral or other health condition? Speech delay, motor delay, prematurity, muscle disease, feeding issues Yes, go to question 4b No, go to question 5 4b. Is this a condition that has lasted or is expected to last for at least 12 months? YES NO 5. Does your child have any kind of emotional, developmental or behavioral problem for which he or she needs or gets treatment or counseling? * Examples: Therapists or psychiatrists for depression, anxiety, ADHD. Neurologist or developmental specialist for developmental delays, ABA therapy for Autism Yes, go to questions 5a No 5a. Has this problem lasted or is it expected to last for at least 12 months? YES NO Checkbox Option 1 Option 2 Thank you! FORMS SUBMITTED.
