Luminis Health OB-GYN – Annapolis Home

(410) 573-9530 Complete Forms

Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein.

Regular Checkup for a Child

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

What questions or concerns do I have about my child that I want addressed during this appointment?




Are there any recent stresses in the family that may be affecting my child, such as death of a loved one, loss of a job, or conflicts? Yes ___ No ___ If yes, describe briefly:


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.

Injury, condition, or disease

Health professional who diagnosed the condition

What was the prescribed treatment?

   
   

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

Name of medicine

What was the medicine for?

  
  
  

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

Medicine or substance

Reaction

  
  

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

Sleeping

Eating

Bowel or bladder

Speech and language

Hearing

Vision

How my child behaves

Physical growth and

coordination

Emotional state

School or daycare

Physical activity

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.

Credits

Current as of: September 20, 2021

Author: Healthwise Staff
Medical Review:
John Pope MD - Pediatrics
Kathleen Romito MD - Family Medicine
Louis Pellegrino MD - Developmental Pediatrics
Susan C. Kim MD - Pediatrics

phone

request an appointment

Office Location