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Forms – Bright Futures Physical 9-10yrs
Bright Futures Physical Exam Pre-visit (9-10 years 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 that are true for your child.
*
Shows the ability to get along with others and control his emotions
Chooses to eat healthy foods and participate in physical activity every day
Forms caring, supportive relationships with family members, other adults, and peers
Risk Assessment
Anemia
Does your child’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?
*
Yes
No
Unsure
Does your child eat a vegetarian diet (does not eat red meat, chicken, fish or seafood)?
*
Yes
No
Unsure
If your child is a vegetarian (does not eat red meat, chicken, fish, or seafood), does your child take an iron supplement?
*
Yes
No
Unsure
Do you ever struggle to put food on the table?
*
Yes
No
Unsure
Hearing
Do you have concerns about how your child hears?
*
Yes
No
Unsure
Do you have concerns about how your child speaks?
*
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
Vision
Do you have concerns about how your child sees?
*
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
Neighborhood and Family Violence (Bullying and Fighting)
Are there frequent reports of violence in your community or school?
*
Yes
No
Has your child ever been bullied or hurt physically by someone?
*
Yes
No
Has your child felt excluded or not a part of any group of friends?
*
Yes
No
Has your child ever told you they were touched in a way that made them uncomfortable or on their private parts?
*
Yes
No
Living Situation and Food Security
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
Do any of your child’s friends smoke, use or vape e-cigarettes, drink alcohol or beer, or use drugs?
*
Yes
No
Harm from the Internet
Do you supervise your child’s internet use?
*
Yes
No
Do you have rules about internet use?
*
Yes
No
Have you installed an internet safety filter on your computers, tablets, and smartphones?
*
Yes
No
Emotional Security and Self-Esteem
Does your child usually seem happy?
*
Yes
No
Are there things your child is really good at doing or is proud of?
*
Yes
No
Does your child have a chance to help others at home, at school, or in your community?
*
Yes
No
Connectedness with Family and Peers
Do your family members get along well with each other?
*
Yes
No
Does your family do things together?
*
Yes
No
Does your child have chores and responsibilities at home?
*
Yes
No
Does your child have friends at school or in your neighborhood?
*
Yes
No
Your Child’s Development
Has your child experienced any recent stresses at home or in school?
*
Yes
No
Do you have clear rules and expectations for your child?
*
Yes
No
When your child breaks the rules, are you consistent with consequences and discipline?
*
Yes
No
Do you help your child control their anger, deal with worries, and solve problems?
*
Yes
No
Have you and your child talked about how to say no to smoking, alcohol, and drug use?
*
Yes
No
Have you talked with your child about the body changes that occur during puberty?
*
Yes
No
Have you discussed privacy and body safety with your child?
*
Yes
No
Have you and your child talked about sex?
*
Yes
No
Does your child know to tell a trusted adult if someone touches their private parts or is someone encourages them to do other things that make them uncomfortable or they know are wrong?
*
Yes
No
School
Do you have concerns about your child’s school experience?
*
Yes
No
Has your child missed more than 2 days of school in any month?
*
Yes
No
Does your child have any difficulties at school or get extra help?
*
Yes
No
Does your child participate in activities outside of school?
*
Yes
No
Healthy Teeth
Does your child brush and floss their teeth every day?
*
Yes
No
Does your child see the dentist twice a year?
*
Yes
No
Does your child use a mouth guard when playing contact sports?
*
Yes
No
Does your child regularly drink soda, juice, or other sugar-sweetened drinks?
*
Yes
No
Nutrition
Do you have any concerns about your child’s weight?
*
Yes
No
Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.?
*
Yes
No
Do you eat family meals together?
*
Yes
No
Do you hear your child talk about how they look or dieting?
*
Yes
No
Physical Activity
Is your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.
*
Yes
No
Do you have any concerns about your child’s physical activity level, such as it being either too much or too little?
*
Yes
No
Does your child have trouble going to sleep or do they wake up during the night?
*
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 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
Safety
Does your child always sit in a belt-positioning booster seat or lap and shoulder seat belt in the back seat every time they ride in a vehicle?
*
Yes
No
Does everyone in the vehicle always use a lap and shoulder seat belt?
*
Yes
No
Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?
*
Yes
No
Does your child know how to swim?
*
Yes
No
Does your child know to always have an adult watching them in the water and never to swim alone?
*
Yes
No
Does your child always use sunscreen when playing outside?
*
Yes
No
Do you know your child’s friends and their families?
*
Yes
No
Does your child know how to get help in an emergency if you aren’t there?
*
Yes
No
Does anyone in your home or the homes where your child spends time have a gun?
*
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 to your child about gun safety?
*
Yes
No
