Well Baby visits (0-18 months)

Welcome.  We want you to have an efficient, low-stress visit where you can focus on your baby’s development and have the time to ask about your concerns.  Here are the forms that we use at well baby visits—please print and complete them at home and bring them to your check-up.

All Bright Futures/asq forms are password protected, as required by copyright agreements. The password is ORP (all capital letters)

Your Child’s Age

Forms to print and complete prior to the visit

Immunizations this visit

2 week

Well Visit Questionnaire, Edinburgh


1 month

Well Baby Questionnaire

2 month

Well Baby Questionnaire

Vaxalis (DTaP-Polio-Hib-Hep B), Prevnar, Rotavirus

4 month

Well Baby Questionnaire

Vaxalis  (DTaP-Polio-Hib-Hep B), Prevnar, Rotavirus

6 month

Well Baby Questionnaire

Vaxalis (DTaP-Polio-Hib-Hep B), Prevnar, Rotavirus,
(Influenza - seasonal)

9 month

Well Baby Questionnaire

 (Influenza- seasonal)

12 months

Well Baby Questionnaire

Varicella (chickenpox), MMR, Hep A #1

15 months

Well Baby Questionnaire

DTaP, Hib, Prevnar

18 month

Well Visit QuestionnaireM-CHAT

Hepatitis A # 2

Forms we use:

Bright Futures: This is a national health promotion and disease prevention toolkit that is supported by the AAP.
Each visit has an age-appropriate pre-visit questionnaire, and information handouts that you will receive after your Well Baby visit.
You will notice the questions focus on developmental milestones, nutrition, safety, your child and family’s emotional well-being, and recommendations from the AAP. Time to complete: 2 minutes

Edinburgh: This tool was developed to screen for depression in pregnant and postpartum mothers. Time to complete: 2 minutes

ASQ (Ages and Stages Questionnaire): This is regarded as the best developmental and social-emotional screening tool for children from one month to 5 ½ years. Since it is parent-completed, it incorporates your expert knowledge of your own children.
Printing this and completing it at home gives you time to really observe your child and record his/her abilities accurately. Time to complete: approx. 5 minutes

M-CHAT: Modified Checklist for Autism in Toddlers, starting at 18 and 30 months.  Time to complete 1 minute