Appointment Line: 970-482-2515

Preparing For Your Upcoming Well-Care Appointment

Click on the links below to find out the specific immunizations, lab work, and paper work required at each well visit.

ASQ (Ages And Stages Questionaires)

The Youth Clinic Utilizes the Ages and Stages Questionaire to assess your child's development. Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

New Patient

Immunizations	Lab Work	Other	Paperwork
			Family Contact Information
			Family Medical History
			FCYC Financial Policy
			Patient Consent
			Patient Information
			TB/Lead Questionnaire

Newborns

Immunizations	Lab Work	Other	Paperwork
			Family Contact Information
			Family Medical History
			FCYC Financial Policy
			Patient Consent
			Patient Information

2 Month

Immunizations	Lab Work	Other	Paperwork
Pediarix (Diptheria, Tetanus, Pertusis, Polio, Hep B)			2 Month ASQ
OR Pentacel (Diptheria, Tetanus, Pertusis, Haemophilus Influenzae Type B, Polio)
Prevnar (Streptococcus Pneumoniae)
Pedvax Hib (Haemophilus Influenzae Type B)
Rotavirus - (Rotavirus)

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

4 Month

Immunizations	Lab Work	Other	Paperwork
Pediarix (Diptheria, Tetanus, Pertusis, Polio, Hep B)			4 Month ASQ
Or Pentacel (Diptheria, Tetanus, Pertusis, Haemophilus Influenzae Type B, Polio)
Prevnar (Streptococcus Pneumoniae)
Pedvax Hib (Haemophilus Influenzae Type B)
Rotavirus - (Rotavirus)

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

6 Month

Immunizations	Lab Work	Other	Paperwork
Pediarix (Diptheria, Tetanus, Pertusis, Polio, Hep B)			6 Month ASQ
OR Pentacel (Diptheria, Tetanus, Pertusis, Haemophilus Influenzae Type B, Polio)			8 Month ASQ
Prevnar (Streptococcus Pneumoniae)
Rotavirus - (Rotavirus)
Pedvax HIB (Haemophilus Influenzae Type B)

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

9 Month

Immunizations	Lab Work	Other	Paperwork
HBV (Hepatitis B) Unless Pediarix Was Given			9 Month ASQ
			10 Month ASQ

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

12 Month

Immunizations	Lab Work	Other	Paperwork
MMR (Measles, Mumps, Rubella)	Hemoglobin		Immunization Screening
Varivax (Varicella)	Lead Screening		TB Lead Questionnaire
Prevnar (Streptococcus Pneumoniae)	PPD		12 Month ASQ
Pedvax HIB (Haemophilus Influenzae Type B)			14 Month ASQ
Hepatitis A			16 Month ASQ

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

18 Month

Immunizations	Lab Work	Other	Paperwork
DTaP (Diptheria, Tetanus, Pertusis)			18 Month ASQ
IPV (Inactivated Polio Vaccine, If Not Pediarix)			20 Month ASQ
Prevnar (Streptococcus Pneumoniae)			22 Month ASQ
Hepatitis A (If Not Given At 12 Month Visit)

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

2 Year

Immunizations	Lab Work	Other	Paperwork
Hepatitis A (If Not Given Previously)	Hemoglobin		TB/Lead Questionnaire
Prevnar (Streptococcus Pneumoniae) If Not Previously Done			24 Month ASQ
			27 Month ASQ
			30 Month ASQ
			33 Month ASQ

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

3 Year

Immunizations	Lab Work	Other	Paperwork
Prevnar (Streptococcus Pneumoniae) If Not Previously Done		Blood Pressure	3 Year ASQ
			42 Month ASQ

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

4 Year

Immunizations	Lab Work	Other	Paperwork
Prevnar (Streptococcus Pneumoniae) If Not Previously Done		Vision Screening	48 Month ASQ
		Hearing Test	54 Month ASQ
		Blood Pressure

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

5 Year

Immunizations	Lab Work	Other	Paperwork
KINRIX (DTAP, IPV combo vaccine)		Vision Screening	60 Month ASQ
		Hearing Test	Immunization Screening
Varivax Booster (Varicella)		Blood Pressure	TB/Lead Questionnaire
MMR (Measles, Mumps, Rubella)
Hepatitis A (If Not Given Previously)
HBV (Hep B)

* Note: Please select and fill out only 1 ASQ form Per Well Care Visit based on the age of your child in months.

6-12 Year

Immunizations	Lab Work	Other	Paperwork
Varivax Booster (Varicella)		Vision Screening
TDaP (Tetanus, Diptheria, Pertusis Ages 10 and Older)		Hearing Test
		Blood Pressure

12-18 Year

Immunizations	Lab Work	Other	Paperwork
Menactra (Meningococcal)	Cholesterol Screen	Vision Screening
Varivax (Varicella)	Hemoglobin	Hearing Test
HBV (Hep B)		Blood Pressure
TDaP (Tetanus, Diptheria, Pertusis)	Pap	Pelvic
Gardasil (Human Papillomavirus)

One Time Visit

Immunizations	Lab Work	Other	Paperwork
			Family Contact Information
			FCYC Financial Policy
			Patient Consent Form
			Patient Info Sheet