Forms – Bright Futures Physical 15-17yrs

Bright Futures Physical Exam Pre-visit (15-17 years old) for Parents
Patient Name*
First Last
Patient'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 teen?
Does your teen have special health care needs?
Have there been major changes lately in your teen’s or family’s life?
Have any of your teen’s relatives developed new medical problems since your last visit?
Does your teen live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
Developmental Screening
Check off each of the items you feel are true for your teen.*
- My teen does things that help them have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping themselves safe
- My teen has at least one adult in their life who care about them and know they can go to if they need help
- My teen has at least one friend or a group of friends who they feel comfortable around
- My teen helps others by themselves or by working with a group in a school, a faith-based organization, or the community
- My teen is able to bounce back when things don’t go their way
- My teen feels hopeful and self-confident
- My teen is becoming more independent and making more decisions on their own as they get older
Risk Assessment
Anemia
Does your teen’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?*
- Yes
- No
- Unsure
Has your teen 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 teen is female, does she have excessive menstrual bleeding or other blood loss?*
- Yes
- No
- Unsure
- Not Applicable
If your teen is female, does her period last more than 5 days?*
- Yes
- No
- Unsure
- Not Applicable
Dyslipidemia
Does your teen 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 teen 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 teen hears?*
- Yes
- No
- Unsure
Oral Health
Does your teen have a dentist?*
- Yes
- No
- Unsure
Does your teen’s primary water source contain fluoride?*
- Yes
- No
- Unsure
Sexually Transmitted infections/HIV
Teens who are sexually active are at risk of sexually transmitted infection, including HIV. Teens who use injection drugs are at risk of HIV. Are you concerned that your teen might be at risk?*
- Yes
- No
- Unsure
Tuberculosis
Was your teen 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 teen had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?*
- Yes
- No
- Unsure
Is your teen infected with HIV?*
- Yes
- No
- Unsure
Vision
Do you have concerns about how your teen sees?*
- Yes
- No
- Unsure
Does your teen have trouble with near or far vision?*
- Yes
- No
- Unsure
Has your teen ever failed a school vision screening test?*
- Yes
- No
- Unsure
Does your teen tend to squint?*
- Yes
- No
- Unsure
Healthy Teeth
Does your teen brush and floss their teeth every day?*
- Yes
- No
Does your teen see the dentist regularly?*
- Yes
- No
Do you have trouble getting dental care?*
- Yes
- No
Nutrition
Do you have any concerns about your teen’s weight, eating habits, or physical activity?*
- Yes
- No
Does your teen talk about getting fat or dieting to lose weight?*
- Yes
- No
Do you think your teen eats healthy foods?*
- Yes
- No
Do you have any difficulty getting healthy food for your family?*
- Yes
- No
Do you eat meals together as a family?*
- Yes
- No
Physical Activity and Sleep
Is your teen 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 exercise outside in your neighborhood?*
- Yes
- No
Do you and your teen participate in physical activities together?*
- Yes
- No
How much time every day does your teen spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting schoolwork)?*
Does your teen 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 teen have a regular bedtime?*
- Yes
- No
Do you think your teen gets enough sleep?*
- Yes
- No
Interpersonal Violence (Bullying and Fighting)
Are there frequent reports of violence in your community or school?*
- Yes
- No
Is your teen involved in that violence?*
- Yes
- No
Has your teen ever been threatened with physical harm or injured in a fight?*
- Yes
- No
Has your teen bullied others?*
- Yes
- No
Has your teen been suspended from school because of fighting, bullying, or carrying a weapon?*
- Yes
- No
Do you know your teen’s friends and the activities they participate in or attend?*
- Yes
- No
If your teen is in a relationship, is it respectful?*
- Yes
- No
Would your teen tell you if someone pressured or forced her to have sex?*
- Yes
- No
Living Situation and Food Security
Do you have concerns about your living situation?*
- 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 teen’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 teen every day?*
- Yes
- No
Does your family do things together?*
- Yes
- No
Does your teen have chores and responsibilities at home?*
- Yes
- No
Do you have clear rules and expectations for your teen?*
- Yes
- No
Does your teen have interests outside of school?*
- Yes
- No
Does your teen help others at home, in school, or in your community?*
- Yes
- No
School
Does your teen get to school on time?*
- Yes
- No
Does your teen attend school almost every day?*
- Yes
- No
Do you recognize your teen’s successes and support their efforts?*
- Yes
- No
Does your teen have plans for after high school?*
- Yes
- No
Coping with Stress and Decision-Making
Have you discussed with your teen ways to deal with stress?*
- Yes
- No
Do you help your teen make decisions or solve problems?*
- Yes
- No
Mood and Mental Health
Is your teen frequently irritable?*
- Yes
- No
Have you noticed changes in your teen’s weight, sleep habits, or behaviors?*
- Yes
- No
Do you have concerns about your teen’s emotional health, such as being frequently sad or depressed?*
- Yes
- No
Do you think your teen worries too much or appears overly anxious?*
- Yes
- No
Healthy Behavior Choices
Have you talked with your teen about relationships, dating, and sex?*
- Yes
- No
Have you talked with your teen about their sexuality?*
- Yes
- No
Do you have house rules about curfews, dating, and friends?*
- Yes
- No
Are you worried about sexual pressures on your teen?*
- Yes
- No
Have you talked with your teen and alcohol and drug use?*
- Yes
- No
To your knowledge, is your teen currently using alcohol or drugs, or have they used them in the past?*
- Yes
- No
Have you discussed consequences if you discover your teen is using tobacco/nicotine, alcohol, or drugs?*
- Yes
- No
Do you know where your teen’s friends are and what they’re doing?*
- Yes
- No
Safety
Does your teen always wear a lap and shoulder seat belt and bicycle helmet?*
- Yes
- No
Do you have rules or restrictions around driving?*
- Yes
- No
Does your teen use sunscreen?*
- Yes
- No
Does your teen often listen to loud music?*
- Yes
- No
Is there a gun in your home or the homes where your teen 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 teen about gun safety?*
- Yes
- No

Forms – Bright Futures Physical 15-17yrs

Bright Futures Physical Exam Pre-visit (15-17 years old) for Parents

Developmental Screening

Risk Assessment

Anemia

Dyslipidemia

Hearing

Oral Health

Sexually Transmitted infections/HIV

Tuberculosis

Vision

Healthy Teeth

Nutrition

Physical Activity and Sleep

Interpersonal Violence (Bullying and Fighting)

Living Situation and Food Security

Alcohol and Drugs

Connectedness with Family, Peers, and Community

School

Coping with Stress and Decision-Making

Mood and Mental Health

Healthy Behavior Choices

Safety