BRIGHT FUTURES 18 Month PHYSICAL-Parent – Child and Family Agency

Bright Futures Physical Exam Pre-visit Form (18 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

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

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

YOUR CHILD’S BEHAVIOR

Do you praise your child for good behavior?*

Yes
No

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

Yes
No

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

Yes
No

Do you use time-outs as a way to manage your child’s behavior?*

Yes
No

Have you thought about toilet training?*

Yes
No

If you are planning to have another baby, have you thought about how you will prepare your child?*

Yes
No
NA

TALKING AND COMMUNICATING

Do you read, sing, and talk with your child about what you are seeing and doing?*

Yes
No

Does he wave “bye-bye”?*

Yes
No

Do you use simple words to tell your child what to do?*

Yes
No

YOUR CHILD AND TV

How much time every day does your child spend watching TV or using computers, tablets, or smartphones?*

Hours

If your child uses media, do you monitor the shows your child watches or activity she does?*

Yes
No

HEALTHY EATING

Do you provide a variety of vegetables, fruits, and other nutritious foods?*

Yes
No

Does your child eat much food that you would describe as junk food?*

Yes
No

Does your child drink water every day?*

Yes
No

Is your child willing to try new foods?*

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

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, fireplaces, and space heaters?*

Yes
No

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

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

Are your TVs, bookcases, and dressers secured to the wall so they cannot fall over and hurt your child?*

Yes
No

Do you have any questions about other ways to keep your home safe?*

Yes
No

Sun Protection

Do you apply sunscreen on your child whenever she plays outside?*

Yes
No

Gun Safety

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