11 - 12 Year Well Visit: PARENT Questionnaire

You may be asked to leave the room for part of the visit. This gives your preteen the opportunity to build a unique relationship with their provider, promotes confidence, full disclosure of health information and improves self-management. That being said, your concerns as a parent are still important to us!

Does you child eat 5 helpings of fruits or vegetables a day?
Does your child drink milk or eat other calcium rich foods?
Do you eat meals together as a family?
Does your child do any physical activities (combined) for at least an hour each day?
Does your child use a helmet or other protective gear when he/she skates, skateboards, bicycles, skis, etc.?
Does your child always wear a seatbelt in a vehicle?
Has your child seen a dentist in the past year?
Do you talk to your child about relationships and sex?
Do you talk with your child about not using alcohol, tobacco, and/or drugs?
Does your child eat more than 1 fast food meal per week?
Does your child drink more than 1 soda, juice or other sweetened drink a day?
Does your child have a problem or worry about weight ( under or overweight)?
Does your child have their own smart phone or tablet?
Does your child have a TV, computer, gaming console in his/her bedroom?
Do you have trouble setting limits on your child's use of electronics outside of use for school?
Is it excessively difficult for your child to stop using electronics when asked?
Do you have difficulty controlling the apps or content your child uses or views?
Do you have any concerns about your child's vision or hearing?
Does your child having problems in school?
Does your child have access to a gun at home or in places where he/she spends time?
If yes, is the gun locked(trigger lock and/or ina a safe) and the ammunition stored separately?
Any concerns or problems with your daughter's period? If yes describe below.
Has your child or anyone in the family developed a new health condition or died?
Any recent changes or challenges at home?

Lipid Screening (a blood test for cholesterol is recommended once between ages 9-11 years old)

Does your child have parents or grandparents who have had a stroke or heart problem before age 55?
Does your child have a parent with an elevated blood cholesterol (240mg/dL) or higher or who is taking cholesterol medicine?

Tuberculosis Screening

Was your child or household member born in, or has he/she traveled to a country where tuberculosis is common? (Include countries in Africa, Asia, Latin America, and Eastern Europe)
Has your child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?

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Oak Harbor, WA 98277

360-675-5555

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1690 Layton Rd.

Freeland, WA 98249

360-331-1314