Peds Response Form printable pdf download

Peds Response Form

Patients Name:_________________________________

Today's Date:___________________

Do you have any concerns about the following:

Yes

A little



How your child understands what you say?



How your child uses his/her hands and/or fingers to do things?



How your child uses his/her arms and legs?



How your child behaves?



How your child gets along with others?



How your child is learning to do things for him/herself?



How your child is learning preschool/school skills?

Please list any other concerns about your child's learning, development, and behavior.

Blood Lead Level Screen

Please check the box next to all that apply:



Do you live in or regularly visit a house built before 1960?

(This could include daycare, preschool, home of babysitter or relative, etc)



Do you live in or regularly visit a home built before 1960 with recent, ongoing, or planned

renovations or remodeling?



Do you have a sibling, housemate, or playmate being followed or treated for lead poisoning?

(That includes a blood level > or = 10 ug/dl)



Do you live with an adult whose job or hobby involves exposure to lead?



Do you live near an active lead smelter, battery recycling plant, or other industry likely to release lead?



Do you give your child any home/folk remedies?

C:\Documents\Pediatric Associates\Marketing\Website\Forms\EXCEL VERSION\3 Year Check-up

Peds Response Form