Staying Healthy Assessment 1-2 years

"*" indicates required fields

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

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 child?*
2. Does your child drink or eat 3 servings of calcium-rich foods daily, such as formula, breast milk, cheese, yogurt, soy milk, or tofu?*
3. Does your child eat fruits and vegetables at least two times per day?*
4. Does your child eat high fat foods, such as fried foods, chips, ice cream, or pizza more than once per week?*
5. Does your child drink more than one small cup (4 – 6 oz.) of juice per day?*
6. Does your child drink soda, juice drinks, sports drinks, energy drinks, or other sweetened drinks more than once per week?*
7. Does your child play actively most days of the week?*
8. Are you concerned about your child’s weight?*
9. Does your child watch TV or play video games?*
10. Does your home have a working smoke detector?*
11. Have you turned your water temperature down to low-warm (less than 120 degrees)?*
12. If your home has more than one floor, do you have safety guards on the windows and gates for the stairs?*
13. Does your home have cleaning supplies, medicines, and matches locked away?*
14. Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone?*
15. Do you always stay with your child when she/he is in the bathtub?*
16. Do you always place your child in a rear facing car seat in the back seat?*
17. Is the car seat you use the right one for the age and size of your child?*
18. Do you always check for children before backing your car out?*
19. Does your child spend time near a swimming pool, river, or lake?*
20. Does your child spend time in a home where a gun is kept?*
21. Does your child always wear a helmet when riding a bike, skateboard, or scooter?*
22. Do you help your child brush and floss her/his teeth daily?*
23. Does your child spend time with anyone who smokes?*
24. Do you have any other questions or concerns about your child’s health, development or behavior?*