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Forms – Bright Futures Physical 4yrs
Bright Futures Physical Exam Pre-visit (4 years old)
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 tasks that your child is able to do.
*
Go to the bathroom and have a bowel movement by themselves
Dress and undress without much help
Play make-believe
Answer questions such as “What do you do when you are cold?” and “When you are sleepy?”
Use 4-word sentences
Speak so strangers can understand 100% of what they say
Draw pictures you recognize
Follow simple rules when playing board or card games
Tell you a story from a book
Skip on one foot
Climb stairs, using one foot, then the other, without support
Draw a person with at least 3 body parts
Draw a simple cross
Unbutton and button medium-sized buttons
Grasp a pencil with a thumb and fingers instead of her fist
Risk Assessment
Anemia
Does your child’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?
*
Yes
No
Unsure
Do you ever struggle to put food on the table?
*
Yes
No
Unsure
Dyslipidemia
Does your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (male) or 65 (female)?
*
Yes
No
Unsure
Does your child have a parent with elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?
*
Yes
No
Unsure
Lead
Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months?
*
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
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
Living Situation and Food Security
Is permanent housing a worry for you?
*
Yes
No
Do you have enough heat, hot water, electricity, and working appliances?
*
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
Does anyone in your household drink beer, wine, or liquor?
*
Yes
No
Do you or other family members use marijuana, cocaine, pain pills, narcotics, or other controlled substances?
*
Yes
No
Intimate Partner Violence
Do you always feel safe in your home?
*
Yes
No
Has your partner, or another significant person in your life, ever hit, kicked, or shoved you, or physically hurt you or your child?
*
Yes
No
Safety in the Community
Do you feel safe in your community?
*
Yes
No
Do you have someone you can turn to if you are concerned about your child’s safety?
*
Yes
No
Do you have connections to your community through faith groups, volunteer organizations, or recreational programs?
*
Yes
No
Do you spend time with parents of other children in your community?
*
Yes
No
Language Understanding and Fluency
Does your child clearly communicate his wants and needs to you and others?
*
Yes
No
Do you respond to your child’s questions with short and simple answers?
*
Yes
No
Do you give your child plenty of time to tell a story or answer a question?
*
Yes
No
Do you talk, sing, and read together every day?
*
Yes
No
Feelings
Is your child generally happy and active?
*
Yes
No
Do you help your child say “I’m sorry” for hurting others’ feelings?
*
Yes
No
Opportunities to Socialize With Other Children
Is your child interested in other children?
*
Yes
No
Does your child have a chance to play with other children in playgroups or at preschool?
*
Yes
No
Does your child have a best friend?
*
Yes
No
Do you praise your child when they are good or have finished a task?
*
Yes
No
Early Childhood Programs and Preschool
Does your child attend preschool?
*
Yes
No
Are you happy with your child care or preschool arrangements?
*
Yes
No
Do you visit your child’s preschool and participate in activities there?
*
Yes
No
Readiness for School
Do you have any concerns about your child starting school in the coming year?
*
Yes
No
Are you doing things to get your child ready for preschool? This could include reading together and going to the library, the park, the zoo, and other places.
*
Yes
No
Eating Healthy: Nutritious Foods
Does your child drink water every day?
*
Yes
No
How many ounces or milk does your child drink on most days?
*
Do you offer your child a variety of foods, including vegetables, fruits, and foods rich in protein, such a meat, eggs, chicken, or fish?
*
Yes
No
Is your child willing to try new flavors and food textures?
*
Yes
No
Do you let your child decide how much to eat and when to stop?
*
Yes
No
Daily Routines that Promote Health
Does your child sleep well?
*
Yes
No
Do you have a regular bedtime and mealtime routines?
*
Yes
No
Do you brush your child’s teeth twice a day with a pea-sized amount of fluoridated toothpaste?
*
Yes
No
Promoting Physical Activity and Limiting TV
How much time every day does your child spend watching TV or using computers, tablets, or smartphones?
*
Does your child have a TV or an Internet-connected device in her 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
Are you physically active together as a family, such as going on walks or playing in the park?
*
Yes
No
Does your child play actively for at least 1 hour a day?
*
Yes
No
Safety
Is your child fastened securely in a car safety seat or belt-positioned booster seat in the back seat every time he rides in a vehicle?
*
Yes
No
Does everyone in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
*
Yes
No
Do you watch your child closely when she plays outside, especially near streets and driveways?
*
Yes
No
Are there swimming pools in your neighborhood?
*
Yes
No
Are you planning to have your child learn to swim?
*
Yes
No
Does your child always wear a US Coast Guard-approved life jacket when on a boat?
*
Yes
No
Does your child always use sunscreen when he plays outside?
*
Yes
No
Do you own a pet?
*
Yes
No
Have you taught your child how to behave around animals so she does not get bitten or scratched?
*
Yes
No
Does anyone in your home or the homes where your child spends time have a gun?
*
Yes
No
If yes, is the gun unloaded and locked up?
*
Yes
No
If yes, is the ammunition stored and locked up separately from the gun?
*
Yes
No
