4 year-old Pre-visit Survey

If you prefer – you may print this survey and bring it with you:

PDF survey

4 year Old Visit Survey

  • Date Format: MM slash DD slash YYYY
  • What Most Children Do at This Age:

  • Act Early by Talking to Your Child's Doctor if Your Child:

  • Tell your child's doctor or nurse if you notice any of these signs of possible developmental delay for this age, and talk with someone in your community who is familiar with services for young children in your area such as your local public school. For more information, go to www.cdc.gov/concerned or call 1-800-CDC-INFO