Wellness Checks - Toddler 1 to 3 Years

Please complete this toddler wellness check form before your scheduled appointment with Virtual Child Health. This helps us review your child’s development, behaviour, sleep, nutrition, and any concerns you would like to discuss during the consultation.

If your child is difficult to wake, has trouble breathing, has blue lips, is not drinking, or has any severe or rapidly worsening symptoms, seek urgent medical care immediately.

Parent or guardian details

Parent or guardian full name*

Address where the child will be during the visit*

Child details

Child's full name*

Telehealth consent

I consent to a video telehealth visit for my child. I understand the limits of telehealth, that some assessments and any vaccines or tests may require an in-person visit, that the clinician may recommend urgent in-person care if needed, and that privacy will be protected as far as possible.

Previsit history

Any behaviour concerns, tantrums, or difficulty with routines?

Nutrition - milk per day, meals, snacks, picky eating, or feeding concerns

What concerns would you like addressed during this visit?*

Screeners

I understand that the relevant ASQ-3 developmental questionnaire may need to be completed if requested or provided before the visit.

I understand that if my child is around 18 or 24 months, or if there are developmental concerns, the M-CHAT-R/F autism screener may also need to be completed if requested.

Have you completed the relevant screener(s), if provided?

Please selectYesNoNot yet sent to me

Visit preparation

Please confirm you will try to have these ready for the visit

A safe play areaA favourite toyA quiet well-lit roomPhone or device fully chargedAny recent growth measurements if available

Optional: is there anything specific you would like us to observe during the visit, such as speech, play, pointing, walking, or behaviour?

Consents

I confirm that I am the parent or legal guardian of this child, or I have authority to complete this form and arrange this appointment on their behalf.

I consent to Virtual Child Health storing and processing the information submitted in order to respond to my enquiry, arrange the appointment, and document the visit in the medical record in line with the clinic privacy policy.

Seek urgent medical care if your child has trouble breathing, becomes difficult to wake, stops drinking, has blue lips, has a seizure, loses previously acquired skills, or develops any severe or rapidly worsening symptoms.