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Forms – Bright Futures Physical 11-14yrs
Bright Futures Physical Exam Pre-visit Form (11-14 year old) for Parents
Child's Name
*
First
Last
Child's Date of Birth
*
MM slash DD slash YYYY
Today's Date
*
MM slash DD slash YYYY
Do you have any concerns, questions, or problems that you would like to discuss?
What excites or delights you most about your child?
Does your child have special health care needs?
Have there been major changes lately in your child’s or family’s life?
Have any of your child’s relatives developed new medical problems since your last visit?
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
Do you have specific concerns about your child's development, learning, or behavior?
Developmental Screening
Check off each of the items you feel are true for your child.
*
My child does things that help them have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping themselves safe
My child has at least one adult in their life who care about them and know they can go to if they need help
My child has at least one friend or a group of friends who they feel comfortable around
My child helps others by themselves or by working with a group in a school, a faith-based organization, or the community
My child is able to bounce back when things don’t go their way
My child feels hopeful and self-confident
My child is becoming more independent and making more decisions on their own as they get older
Risk Assessment
Anemia
Does your child’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?
*
Yes
No
Unsure
Has your child ever been diagnosed with iron deficiency anemia?
*
Yes
No
Unsure
Does your family ever struggle to put food on the table?
*
Yes
No
Unsure
If your child is female, does she have excessive menstrual bleeding or other blood loss?
*
Yes
No
Unsure
Not Applicable
If your child is female, does her period last more than 5 days?
*
Yes
No
Unsure
Not Applicable
Dyslipidemia
Does your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (males) or 65 (females)?
*
Yes
No
Unsure
Does your child have a parent with an elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?
*
Yes
No
Unsure
Hearing
Do you have concerns about how your child hears?
*
Yes
No
Unsure
Oral Health
Does your child have a dentist?
*
Yes
No
Unsure
Does your child’s primary water source contain fluoride?
*
Yes
No
Unsure
Sexually Transmitted infections/HIV
Adolescents who are sexually active are at risk of sexually transmitted infection, including HIV. Adolescents who use injection drugs are at risk of HIV. Are you concerned that your young adolescent might be at risk?
*
Yes
No
Unsure
Adolescents who use injection drugs are at risk of HIV. Are you concerned that your young adolescent might be at risk?
*
Yes
No
Unsure
Tuberculosis
Was your child or any household member born in, or has he or she traveled to, a country where tuberculosis is common (this includes countries in Africa, Asia, Latin America, and Eastern Europe)?
*
Yes
No
Unsure
Has your child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
*
Yes
No
Unsure
Is your child infected with HIV?
*
Yes
No
Unsure
Vision
Do you have concerns about how your child sees?
*
Yes
No
Unsure
Does your child have trouble with near or far vision?
*
Yes
No
Unsure
Has your child ever failed a school vision screening test?
*
Yes
No
Unsure
Does you child tend to squint?
*
Yes
No
Unsure
Healthy Teen
Does your child brush and floss their teeth every day?
*
Yes
No
Does your child see the dentist regularly?
*
Yes
No
Do you have trouble getting dental care?
*
Yes
No
Nutrition
Do you have any concerns about your child’s nutrition, weight, eating habits, or physical activity?
*
Yes
No
Does your child talk about getting fat or dieting to lose weight?
*
Yes
No
Do you think your child eats healthy foods?
*
Yes
No
Do you have any difficulty getting healthy food for your family?
*
Yes
No
Do you have any concerns about your child’s eating habits or nutrition?
*
Yes
No
Do you eat meals together as a family?
*
Yes
No
Physical Activity and Sleep
Is your child physically active at least 1 hour every day? This includes running, playing sports, or doing physically active things with friends.
*
Yes
No
Are there opportunities to safely play outside in your neighborhood?
*
Yes
No
Do you and your child participate in physical activities together?
*
Yes
No
How much time every day does your child spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting schoolwork)?
*
Does your child have a TV, computer, tablet, or smartphone in their bedroom?
*
Yes
No
Has your family made a media use plan to help everyone balance time spent on media with other family and personal activities?
*
Yes
No
Does your child have a regular bedtime?
*
Yes
No
Interpersonal Violence (Bullying and Fighting)
Are there frequent reports of violence in your community or school?
*
Yes
No
Is your child involved in any of the violence?
*
Yes
No
Do you think your child is safe in the neighborhood?
*
Yes
No
Has your child ever been injured in a fight?
*
Yes
No
Has your child been bullied or hurt by others?
*
Yes
No
Has your child bullied or been aggressive toward others?
*
Yes
No
Have you talked to your child about violence in dating situations and how to be safe?
*
Yes
No
Living Situation and Food Security
Do you have concerns about your living situation?
*
Yes
No
Do you have enough heat, hot water, and electricity?
*
Yes
No
Do you have appliances that work?
*
Yes
No
Do you have problems with bugs, rodents, or peeling paint or plaster?
*
Yes
No
Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?
*
Yes
No
Within the past 12 months, did the food you bought not last, and did you not have money to get more?
*
Yes
No
Alcohol and Drugs
Is there anyone in your child’s life whose alcohol or drug use concerns you?
*
Yes
No
Connectedness with Family, Peers, and Community
Do your family members get along well with each other?
*
Yes
No
Do you take time to talk with your child every day?
*
Yes
No
Does your family do things together?
*
Yes
No
Does your child have chores and responsibilities at home?
*
Yes
No
Do you have clear rules and expectations for your child?
*
Yes
No
Do you let your child know when they do something good?
*
Yes
No
Does your child have interests outside of school?
*
Yes
No
Does your child help others at home, in school, or in your community?
*
Yes
No
School
Is your child getting to school on time?
*
Yes
No
Is your child having any problems at school?
*
Yes
No
Does your child complete homework on time?
*
Yes
No
Has your child missed more than 2 days of school in any month?
*
Yes
No
Coping with Stress and Decision-Making
Does your child worry too much or appear overly anxious?
*
Yes
No
Have you discussed ways to deal with stress?
*
Yes
No
Do you help your child make decisions or solve problems?
*
Yes
No
Mood and Mental Health
Is your child frequently irritable?
*
Yes
No
Have you noticed changes in your child’s weight or sleep habits?
*
Yes
No
Do you and your child often have conflicts about what your culture expects for their behavior and how their friends behave?
*
Yes
No
Do you have any concerns about your child’s emotional health, such as being frequently sad or depressed?
*
Yes
No
Healthy Behavior Choices
Have you and your child talked about how their body will change during puberty?
*
Yes
No
Do you have house rules about curfews, dating, and friends?
*
Yes
No
Have you and your child talked about sex?
*
Yes
No
Have you talked about ways to deal with any pressures to have sex?
*
Yes
No
Have you talked with your child and alcohol and drug use?
*
Yes
No
Do you know your child’s friends?
*
Yes
No
Do you know where your child is and what they do after school and on the weekends?
*
Yes
No
Do you have consequences for your child if you discover they are using tobacco/nicotine, alcohol, or drugs?
*
Yes
No
To your knowledge, is your child currently using alcohol or drugs, or have they used them in the past?
*
Yes
No
Safety
Do you always wear a lap and shoulder seat belt and bicycle helmet?
*
Yes
No
Do you insist your child wears a lap and shoulder seat belt when in the car?
*
Yes
No
Do you insist that your child use a life jacket when they do water sports?
*
Yes
No
Does your child know how to swim?
*
Yes
No
Does your child use sunscreen?
*
Yes
No
Does your child often listen to loud music?
*
Yes
No
Is there a gun in your home or the homes where your child visits?
*
Yes
No
Is the gun unloaded and locked up?
*
Yes
No
Is the ammunition stored and locked up separately from the gun?
*
Yes
No
Have you talked with your child about gun safety?
*
Yes
No
