260 San Jose St.
Salinas CA 93901
(831)757-8124
Spanish friendly staff
Amable personal bilingue

Staying Healthy Assessment 0-6 months

"*" indicates required fields

Child’s Name (first & last)*
Date of Birth*
Today's Date*
Gender*
In Child/Day Care?*
Relationship*

Specify if other

Please answer all the questions on this form as best you can. Circle “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.

1. Do you breastfeed your baby?*
2. Are you concerned about your baby’s weight?*
3. Does your baby watch any TV?*
4. Does your home have a working smoke detector?*
5. Have you turned your water temperature down to low-warm (less than 120 degrees)?*
6. If your home has more than one floor, do you have safety guards on the windows and gates for the stairs?*
7. Does your home have cleaning supplies, medicines, and matches locked away?*
8. Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone?*
9. Do you always put your baby to sleep on her/his back?*
10. Do you always stay with your baby when she/he is in the bathtub?*
11. Do you always place your baby in a rear facing car seat in the back seat?*
12. Is the car seat you use the right one for the age and size of your baby?*
13. Does your baby spend time in a home where a gun is kept?*
14. Do you give your baby a bottle with anything except formula, breast milk, or water?*
15. Does your baby spend time with anyone who smokes?*
16. Do you have any other questions or concerns about your baby’s health, development, or behavior?*