Parent Health Questionnaire Page 2
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1
2HEARING
Has your child had ear infections? Yes
No
How many in the past year?
How many times has he/she been to the doctor for ear infections and what was the treatment?
Did your child have a newborn hearing screening?
Yes _____ No _____ Results _______________
Has your child had a hearing examination or treatment since then? Yes _____ No _____
If yes, when?
By whom?
Results ____________________________
Please check “yes” or “no” to the following observations and/or concerns as they relate to your child.
YES NO
1. Seems to hear you if you talk in a whisper……………………………………………………….
2. Seems to speak as well as other children the same age…………………………………………….
3. There is a history of hearing problems in the family……………………………………………..
4. Seems to have difficulty hearing……………………………………………………………………..
5. Turns up the TV louder than other members of the family……………………………………….
6. Seems to favor one ear over the other………………………………………………………………
7. Wants you to talk loudly or repeat frequently………………………………………………………
8. Seems to be oversensitive to noise ……………………………………………………………..
DENTAL
Does anything on your child’s teeth or gums appear abnormal (swelling, redness, apparent decay)?
Yes ___ No___ If yes, describe.____________________________________________________________
Is brushing teeth part of your child’s regular daily routine? Yes ____ No ____
Did or does your child fall asleep with a bottle in his/her mouth? Yes ____ No ____
SLEEP
Does your child have a regular nap time? Yes _____ No _____
Does your child have a regular bed time? Yes _____ No _____
If yes, what time? _____________
How many hours does your child sleep per day/night? ________________
Describe any concerns you have about your child’s sleep _______________________________________
__________________________________________________________________________________________
HEALTH and NUTRITION
According to your healthcare provider, are your child’s size and weight ok? Yes _____ No _____
Do you think your child eats a variety of nutritious foods? Yes _____ No _____
Describe any concerns you have about your child’s eating ______________________________________
Has your child been screened for lead level? Yes _____ No _____ Results_______________________
Has your child been screened for anemia? Yes _____ No _____ Results _________________________
SAFETY
Does your child ride in an approved safety seat in the back seat of the car? Yes _____ No _____
If your child is involved in biking or skating, is a helmet used? Yes _____ No _____
Signature of person completing form
Today’s Date
Rev. 2016
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