Wellness Checks - Infants 4 Months - 1 Year

Please complete this infant wellness check form before your scheduled appointment with Virtual Child Health. This helps us review your baby's growth, feeding, development, and any concerns you would like to discuss during the consultation.

If your child has difficulty breathing, blue lips, is not feeding, is unusually drowsy, or has a persistent high fever, 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 in-person visits are required for vaccines and blood tests, that the clinician may recommend urgent in-person care if needed, and that privacy will be protected as far as possible.

Previsit history

Feeding

Recent illnesses, hospital visits, or emergency visits since the last review

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 for 9-month or 12-month visits, a developmental milestone checklist may also be requested.

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

Please selectYesNoNot yet sent to me

Measurement and visit preparation

Do you have a recent clinic or home weight for your child?

Please selectYesNo

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

Recent weight or clinic growth recordBottles, feeding details, or usual milk intakeA few small toys for developmental observationA quiet well-lit roomPhone or device fully charged

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 develops poor feeding, fewer wet diapers than expected, persistent vomiting, difficulty breathing, blue lips, marked drowsiness, a seizure, or a persistent high fever.