Date of Visit ____________________
What is the main reason that you have brought your child to your Pediatrician today?
When did she start getting sick? Has she been around anyone who is sick?
What are his symptoms? Does she have... (circle all that apply)?
runny nose | cough | fever | vomiting
diarrhea | trouble breathing | irritability
trouble sleeping | poor appetite | rash | ear pain
Other symptoms:
When are her symptoms better and worse? How have they changed?
What treatments and medications have you been giving your child?
Information to record from your visit:
Your child's diagnosis:
Treatment instructions and prescribed medications:
When should she start getting better?
What signs should you look for that may mean your child is getting worse?
When should you return for a recheck?
This worksheet was reproduced from The Everything® Father's First Year Book Copyright 2005, F+W Publications, Inc.
The Everything® Father's First Year Book by Vincent Iannelli, MD is published by Adams Media and is now available at your favorite bookstore.
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