Forms & Questionnaires (5 Years Old and Under)
Germantown Pediatric & Family Medicine
Here you can find important information, forms, and questionnaires for the first 5 years of your child.
- Newborn Visits.
- 2 Months Visit.
- 4 Months Visit.
- 6 Months Visit.
- 9 Months Visit.
- 12 Months Visit.
- 15 Months Visit.
- 18 Months Visit.
- 24 Months Visit.
- 30 Months Visit.
- Three Year Check-Up.
- Four Year Check-Up.
- Five Year Check-Up.
Newborn
Visits
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Congratulations, and thank you for choosing our practice as your child's medical home, where we always provide a comfortable, caring environment so our patients and their families can feel at ease. Please click the link below and submit the form at least a day prior to your visit if possible.
2 Months Visit Immunizations
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During two-month checkups, most babies will be immunized against seven or eight different diseases. Typical immunizations given during your child's 2-month checkup include: Pediarix (a combination vaccine containing DTaP, Hep B, IPV), Hib vaccine, Prevnar vaccine, and rotavirus vaccine. Here is the Information sheet on the vaccines that your baby will receive at the 2-, 4- and 6-month visits.
2 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 2 months and 30 days.
- ASQ 2m (1 month 0 days through 2 months 30 days)
- Edinburgh Postnatal Depression Scale (EPDS)
- ASQ 2m Spanish (1 month 0 days through 2 months 30 days)
4 Months Visit Immunizations
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During four-month checkups, most babies will be immunized against seven or eight different diseases. Typical immunizations given during your child's 4-month checkup include: Pediarix (a combination vaccine containing DTaP, Hep B, IPV), Hib vaccine, Prevnar vaccine, and rotavirus vaccine. Here is the Information sheet on the vaccines that your baby will receive at the 4-month visit.
4 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 5 months old.
- ASQ 4m (3 months 0 days through 4 months 30 days)
- Edinburgh Postnatal Depression Scale (EPDS)
- ASQ 4m Spanish (3 months 0 days through 4 months 30 days)
6 Months Visit Immunizations
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During six-month checkups, most babies will be immunized against seven or eight different diseases. Typical immunizations given during your child's 6-month checkup include Pediarix ( a combination vaccine containing DTaP, Hep B, IPV), Hib vaccine, Prevnar vaccine, and rotavirus vaccine. Here is the Information sheet on the vaccines that your baby will receive at the 6-month visit. Your baby may also need the Influenza vaccine.
6 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 7 months old.
- ASQ 6m (5 months 0 days through 6 months 30 days)
- Edinburgh Postnatal Depression Scale (EPDS)
7 to 9 Months Visit
ASQ Form
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Please note that if your child is between 7 to 9 months, please click the link below for the correct ASQ that matches the child's age.
9 Months Visit Immunizations
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During nine-month checkups, babies usually do not need any immunizations, except maybe the Influenza vaccine. If your baby is getting the influenza vaccine for the first time, please make sure to schedule an appointment in one month for the second dose.
9 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 10 months old.
- ASQ 9m (9 months 0 days through 9 months 30 days)
12 Months Visit Immunizations
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At the twelve-month visit, the vaccines given include MMR, Varivax or chickenpox vaccine, and the first Hepatitis A vaccine. Your child may be due for a flu vaccine as well. Please note that these vaccines must be given on or after the first birthday.
Here is the information sheet on the vaccines that your child will be receiving.
- CDC MMR Vaccine Statements - Spanish
- CDC Varicella Vaccine Statements
12 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 12 months and 30 days.
- ASQ 12m (11 months 0 days through 12 months 30 days)
- ASQ 12m Spanish (11 months 0 days through 12 months 30 days)
15 Months Visit Immunizations
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At the fifteen-month visit, your child will receive the Hib and Prevnar vaccines. Your child may receive a flu vaccine and if there are any vaccines due from previous visits. Here is the information sheet on the vaccines that your child will be receiving.
- CDC Hepatitis A Vaccine Statements
13-14 Months Visit
ASQ Form
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If your baby is between 13 months 0 days to 14 months 30 days, use this ASQ questionnaire.
- ASQ 13 months 0 days to 14 months 30 days
15 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 15 months and 16 months 30 days.
- ASQ 15m (15 months 0 days through 16 months 30 days)
- ASQ 15m (15 months 0 days through 16 months 30 days) - Spanish
12-16 Months
Intervention Sheet
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16-20 Months
Intervention Sheet
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18 Months Visit Immunizations
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At the eighteen-month visit, your child will receive a DTaP vaccine and the second Hepatitis A vaccine. The second Hepatitis vaccine is given six months after the first one. Here is the information sheet on the vaccines below. Your child may also need a flu vaccine.
18 Months Visit Checklist for Autism in Toddlers
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Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)
The American Academy of Pediatrics recommends the Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire to screen for autism. The M-CHAT-R is a revised, updated version that is more user-friendly and provides more accurate results.
18 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. Please ensure to pick the form that matches the child’s age.
- ASQ 18m (17 months 0 days through 18 months 30 days)
- ASQ 18m (17 months 0 days through 18 months 30 days) - Spanish
If your child is here for an 18-month visit but is between 19 months to 19 months and 30 days, please fill out this form.
- ASQ between 19 m to 19 m and 30 days
- ASQ 19 m to 19 m and 30 days - Spanish
If your child is here for an 18-month visit but is between 21 months to 22 months and 30 days, please fill out this form.
- ASQ between 21 m to 22 m and 30 days
20-24 Months Visit
Intervention Sheet
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24 Months Visit Immunizations
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By this visit, your child should have completed the primary immunization series and will not need routine vaccines till kindergarten. Please bring any previous immunization records.
24 Months Visit Checklist for Autism in Toddlers
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Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R)
The American Academy of Pediatrics recommends the Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire to screen for autism. The M-CHAT-R is a revised, updated version that is more user-friendly and provides more accurate results.
23-25 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. Please ensure to pick the form that matches the child’s age.
If your child is between 23 months to 25-months-15 days, please fill out this form.
- ASQ 24m (23 months 0 days through 25 months 15 days)
- ASQ 24m (23 months 0 days through 25 months 15 days) - Spanish
25-28 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. Please ensure to pick the form that matches the child’s age.
If your child is between 25 months 16 days to 28 months 15 days, use this form.
- ASQ (25 months 16 days to 28 months 15 days)
24-30 Months
Intervention Sheet
30 Months Visit Immunizations
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By this visit, your child should have completed the primary immunization series and will not need routine vaccines till kindergarten. Please bring any previous immunization records.
30 Months Visit
ASQ Form
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 28 months 16 days to 31 months 15 days.
- ASQ 30m (28 months 16 days through 31 months 15 days)
- ASQ 30m (28 months 16 days through 31 months 15 days) - Spanish
30-36 Months
Intervention Sheet
3 Year Check-Up
Immunizations
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By this visit, your child should have completed the primary immunization series and will not need routine vaccines till kindergarten. Please bring any previous immunization records.
3 Year Check-Up
ASQ Form (34-38 Months)
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 34 months, 16 days to 38 months, 30 days.
- ASQ 36m (34 months 16 days through 38 months 30 days)
- ASQ 36m (34 months 16 days through 38 months 30 days) - Spanish
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. If your child is between 39 months 0 days to 44 months 30 days, use this form.
- ASQ 42m (39 months 0 days to 44 months 30 days)
3 Year Check-Up
Intervention Sheet
4 Year Check-Up
Immunizations
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Your child can receive the kindergarten vaccines any time after the fourth birthday. Please bring any previous immunization records. The kindergarten vaccines include the second MMR, the second Chickenpox or varivax vaccine, and the booster DTaP and IPV vaccines. Please take the time to read the information on the vaccines below.
- CDC MMR Vaccine Statements - Spanish
- CDC Varicella Vaccine Statements
- CDC Varicella Vaccine Statements - Spanish
- CDC DTaP Vaccine Statements - Spanish
4 Year Check-Up
ASQ Forms
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 48 months to 50 months 30 days.
- ASQ 48m (45 months 0 days through 50 months 30 days)
- ASQ 48m (45 months 0 days through 50 months 30 days) - Spanish
4 Year Check-Up
Intervention Sheet
5 Year Check-Up
Immunizations
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Your child can receive the kindergarten vaccines any time after the fourth birthday. Please bring any previous immunization records. The kindergarten vaccines include the second MMR, the second Chickenpox or varivax vaccine, and the booster DTaP and IPV vaccines. Please take the time to read the information on the vaccines below.
- CDC MMR Vaccine Statements - Spanish
- CDC Varicella Vaccine Statements
- CDC Varicella Vaccine Statements - Spanish
- CDC DTaP Vaccine Statements - Spanish
5 Year Check-Up
ASQ Forms
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The link below will take you to the ASQ form that needs to be completed about 5 days before your scheduled visit. This way, we are able to review and be prepared for your child's upcoming visit. The ASQ is valid till your child is 4 years 9 months to 5 years and 6 months.
- ASQ 60m (57 months 0 days through 66 months 0 days)
- ASQ 60m (57 months 0 days through 66 months 0 days) - Spanish
5 Year Check-Up
Intervention Sheet
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