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If yes, please describe:  \n________________________________________________________________________________________  \nDoes your baby take any medications or supplements, □ No □ Yes:    \nincluding vitamins? If yes, please list.  \nDoes your baby have known allergies to foods/medicines? If yes, please list.  \n□ No □ Yes:    \nDo you have concerns about your baby’s hearing/vision? □ No □ Yes:    \nDoes your baby see any specialists outside of ORP? □ No □ Yes:    \nDoes your water contain fluoride? (City water contains fluoride) □ Yes □ No  \nNutrition:  \nWhat type (s) of milk is your child drinking? □ Whole milk □ Breast milk □ Other   \nAre they usually getting 2-3 servings of dairy a day (8 oz milk=1 serving)? □ Yes □ No  \nAre they usually drinking MORE than 24 oz of milk a day? □ No □ Yes  \nIs your child completely off the bottle? □ Yes □ No  \nAre they eating iron rich foods daily (meat, beans, iron vitamin, cheerios/cereal)? □ Yes □ No  \nDoes your child   \n\n| Copy other children while playing, like taking toys out of a container when another child does? | Yes | No |\n| --- | --- | --- |\n| Show you an object that he likes? | Yes | No |\n| Clap when excited? | Yes | No |\n| Hug a stuffed doll or other toy? | Yes | No |\n| Show you affection (hugs, cuddles, or kisses you)? | Yes | No |\n| Try to say 1-2 words besides mama or dad like “ba” for ball or “da” for dog? | Yes | No |\n| Look at a familiar object when you name it? | Yes | No |\n| Follow directions given with both a gesture and words. For example, he gives you a toy when you hold out your hand and say,“Give me the toy”? | Yes | No |\n| Points to ask for something or to get help? | Yes | No |\n| Try to use things the right way, like a phone, cup, or book? | Yes | No |\n| Stack at least 2 small objects, like blocks? | Yes | No |\n| Take a few steps on his own? | Yes | No |\n| Use fingers to feed herself some food? | Yes | No |\n\nWho lives at home with your child?    \nAre parents: single married divorced separated widowed  \nWho takes care of your child during the day?   Have there been major changes lately in your baby’s or family’s life?   Will your child travel internationally prior to their 2nd birthday? If yes, when and where:    \n\n| Does your child point to something he wants and then\u003Cbr>watch to see if you see what he’s doing? Yes No |\n| --- |\n| Does she wave “bye-bye”? Yes No |\n| Do you talk to, sing to, and look at books with your child every day? Yes No |\n| Does your child have a regular bedtime routine? Yes No |\n| Does your child usually sleep well? Yes No |\n| Does your child have a blanket, stuffed animal, or toy that he likes to sleep with? Yes No |\n| Do you have a TV or an Internet-connected device in your child’s bedroom? No Yes |\n| Does your child have frequent tantrums? No Yes |\n| If your child is upset, do you help distract her with another activity, book, or toy? Yes No |\n| Do you praise your child when he is being good? Yes No |\n| Do you brush your child’s teeth with a smear of fluoridated toothpaste 2 times a day? Yes No |\n| Is your child in a rear facing car seat every time they are in the car? Yes No |\n| Do you keep cleaners and medicines locked up? Yes No |\n| Do you keep furniture away from windows? Yes No |\n| Do you have a gate at the top and bottom of all stairs in your home? Yes No |\n| If you have a pool, does it have a locked gate? Yes No |\n| Do you keep your child away from the stove? Yes No |\n| Do you have working smoke alarms on all floors? Yes No |\n| Do you test your smoke alarms once a month? Yes No |\n| Do you offer your child a variety of foods including vegetables, fruits, and proteins? Yes No |\n| Do you let your child decide what to eat and how much? Yes No |\n| Does your child drink sugar sweetened beverages: juice/soda/sports drinks daily? No Yes |\n|  |\n| Is permanent housing a concern for you? No Yes |\n| Do you have the ","cbCaicvAlQ7NAPz0","https://ap.wps.com/l/cbCaicvAlQ7NAPz0","pdf",124824,"English","# Well Child Check\n## Parent concerns and medical history\n## Nutrition, development, and daily routines\n## Home environment and safety","[{\"question\":\"What parent-reported topics are collected in the 15 month visit form?\",\"answer\":\"\"},{\"question\":\"How does the form evaluate nutrition and feeding at 15 months?\",\"answer\":\"\"},{\"question\":\"What safety and home environment screening questions are included?\",\"answer\":\"The form asks about TV/Internet devices in the bedroom and many home safety measures such as rear-facing car seat use, locked medicines/cleaners, furniture away from windows, gates for stairs, pool locked gates (if applicable), stove safety, smoke alarms and testing, and keeping the child away from hazards.\"}]","Well Child Check - 15 Month Visit - Questionnaire | PDF",1789127319]