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?*

Parent wellbeing - Edinburgh Postnatal Depression Scale (EPDS)

Please select the answer that comes closest to how you have felt in the past 7 days.

1. I have been able to laugh and see the funny side of things

Please selectAs much as I always couldNot quite so much nowDefinitely not so much nowNot at all

2. I have looked forward with enjoyment to things

Please selectAs much as I ever didRather less than I used toDefinitely less than I used toHardly at all

3. I have blamed myself unnecessarily when things went wrong

Please selectYes, most of the timeYes, some of the timeNot very oftenNo, never

4. I have been anxious or worried for no good reason

Please selectNo, not at allHardly everYes, sometimesYes, very often

5. I have felt scared or panicky for no very good reason

Please selectYes, quite a lotYes, sometimesNo, not muchNo, not at all

6. Things have been getting on top of me

Please selectYes, most of the time I haven't been able to cope at allYes, sometimes I haven't been coping as well as usualNo, most of the time I have coped quite wellNo, I have been coping as well as ever

7. I have been so unhappy that I have had difficulty sleeping

Please selectYes, most of the timeYes, sometimesNot very oftenNo, not at all

8. I have felt sad or miserable

Please selectYes, most of the timeYes, quite oftenNot very oftenNo, not at all

9. I have been so unhappy that I have been crying

Please selectYes, most of the timeYes, quite oftenOnly occasionallyNo, never

10. The thought of harming myself has occurred to me

Please selectYes, quite oftenSometimesHardly everNever

If you have had thoughts of harming yourself or your baby, or you feel you are in immediate danger, seek urgent emergency help immediately.

EPDS copyright notice: Cox, J.L., Holden, J.M., and Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.

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.