Bright Futures 9 Month Physical-Parent – Child and Family Agency

Bright Futures Physical Exam Pre-visit Form (9 Month Visit) for Parents

Patient's Name*

First Last

Patient'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 baby?

Does your baby have special health care needs?

Have there been major changes lately in your baby's or family’s life?

Have any of your baby's relatives developed new medical problems since your last visit?

Does your baby live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?

Do you have specific concerns about your baby's development, learning, or behavior?

Developmental Screening

Check off each of the task that your baby is able to do.*

RISK ASSESSMENT

Hearing

Do you have concerns about how your baby hears?*

Yes
No
Unsure

Lead

Does your baby 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 that was renovated in the past 6 months?*

Yes
No
Unsure

Oral Health

Does your baby’s primary water source contain fluoride?*

Yes
No
Unsure

Vision

Do you have concerns about how your baby sees?*

Yes
No
Unsure

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

Yes
No
Unsure

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

Yes
No
Unsure

Have your baby’s eyes ever been injured?*

Yes
No
Unsure

ANTICIPATORY GUIDANCE

YOUR FAMILY’S HEALTH AND WELL-BEING

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 the baby?*

Yes
No

Have you developed routines or other ways to take care of yourself?*

Yes
No

CARING FOR YOUR BABY

Do you have a regular bedtime routine for your baby?*

Yes
No

Does she wake up during the night?*

Yes
No

Is your baby learning new things?*

Yes
No

Does your baby have ways to tell you what he wants and needs?*

Yes
No

Is a TV, computer, tablet, or smartphone on in the background while your baby is in the room?*

Yes
No

Does your baby watch TV or play on a tablet or smartphone? If yes, how much time each day? (Hours)

Have you made a family media use plan to help you balance media use with other family activities?*

Yes
No

DISCIPLINE

Do you and your partner agree on how to handle your baby’s behavior?*

Yes
No

Do you limit the use of “No” to only the most important issues?*

Yes
No

If you have other children, do you let them help with the baby as much as they can?*

Yes
No
NA

FEEDING YOUR BABY

Does your baby feed herself?*

Yes
No

Does your baby drink from a cup?*

Yes
No

Do you let your baby decide what and how much to eat?*

Yes
No

Do you give your baby foods with different textures (such as pureed, blended, mashed, chopped, or lumps)?*

Yes
No

If you are breastfeeding, are you planning on continuing?*

Yes
No
NA

Car and Home Safety

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

Yes
No

Do you have any habits or reminders that prevent you from ever leaving your baby in the car?*

Yes
No

Do you keep your baby away from the stove, fireplaces, and space heaters?*

Yes
No

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

Yes
No

Do you always stay within arm’s reach of your baby when she is in the bathtub?*

Yes
No

Do you keep furniture away from windows and use operable window guards on second-floor and higher windows? (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

Gun Safety

Does anyone in your home or the homes where your baby 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