Bright Futures 15 Month Physical-Parent – Child and Family Agency

Bright Futures Physical Exam Pre-visit Form (15 Month Visit) for Parents

Child's Name*

First Last

Child's Date of Birth*

Today's Date*

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 task that your child is able to do.*

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

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

Vision

Do you have concerns about how your child sees?*

Yes
No
Unsure

Do your child’s eyes appear unusual or seem to cross?*

Yes
No
Unsure

Do your child’s eyelids droop or does one eyelid tend to close?*

Yes
No
Unsure

Have your child’s eyes ever been injured?*

Yes
No
Unsure

ANTICIPATORY GUIDANCE

TALKING AND FEELING

Is your child learning new things?*

Yes
No

Does your child show any worries or fears when meeting new people?*

Yes
No

Do you take time for yourself?*

Yes
No

Do you spend time alone with your partner?*

Yes
No

Does your child point to something he wants and then watch to see if you see what he’s doing?*

Yes
No

Does she wave “bye-bye”?*

Yes
No
NA

Do you talk to, sing to, and look at books with your child every day?*

Yes
No
NA

SLEEP ROUTINES AND ISSUES

Does your child have a regular bedtime routine?*

Yes
No

Does your child sleep well?*

Yes
No

How many hours does your child sleep?

Daytime

How many hours does your child sleep?

Nighttime

Does your child have a blanket, stuffed animal, or toy that he likes to sleep with?*

Yes
No

Do you have a TV or an Internet-connected device in your child’s bedroom?*

Yes
No

TANTRUMS AND DISCIPLINE

Does your child have frequent tantrums?*

Yes
No

If your child is upset, do you help distract her with another activity, book, or toy?*

Yes
No

Do you set limits for your child?*

Yes
No

Do other caregivers set the same limits for your child as you do?*

Yes
No

Do you praise your child when he is being good?*

Yes
No

Do you have any questions about what to do when you become angry or frustrated with your child?*

Yes
No

HEALTHY TEETH

Has your child been to a dentist?*

Yes
No

Do you brush your child’s teeth with a smear of fluoridated toothpaste 2 times a day using a soft toothbrush?*

Yes
No

Does your child use a bottle?*

Yes
No

SAFETY

Car and Home Safety

Is your child fastened securely in a rear-facing car safety seat in the back seat every time he rides in a vehicle?*

Yes
No

Does everyone in the car always use a lap and shoulder seat belt, booster seat, or car safety seat?*

Yes
No

Do you keep cleaners and medicines locked up and out of your child’s sight and reach?*

Yes
No

Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?*

Yes
No

Do you keep furniture away from windows and use operable window guards on windows on the second floor and higher? (Operable means that, in case of an emergency, an adult can open the window.)*

Yes
No

Do you have a gate at the top and bottom of all stairs in your home?*

Yes
No

Do you keep cigarettes, lighters, matches, and alcohol out of your child’s sight and reach?*

Yes
No

Do you keep your child away from the stove?*

Yes
No

Do you have working smoke alarms on every floor of your home?*

Yes
No

Do you test the batteries once a month?*

Yes
No

Do you have a fire escape plan?*

Yes
No