BRIGHT FUTURE PHYSICAL-AGE 6

Bright Futures Physical Exam Pre-visit (6 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.*
- Ride a standard bike
- Hop on one foot 3 to 4 times
- Catch a small ball with 2 hands
- Draw a 12-part person
- Write first and last names in uppercase or lowercase letters
- Cut most foods with a knife
- Tie shoes
- Is dry day and night
- Tell a story with a beginning, a middle, and an end
- Choose preferred foods at breakfast and lunch
- Start and continue a conversation with peers
- Master all consonant sounds and combinations, such as “d” or “ch”
- Play and interact with at least one “best friend”
- Print 3 or more simple words without copying
- Count 10 objects
- Do simple addition and subtraction with objects
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 an 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
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 every bullied or been aggressive with others?*
- 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
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
Connectedness with Family and Peers
Does your family get along well with each other?*
- Yes
- No
Does your family do things together?*
- Yes
- No
Family Rules and Routines
Does your child have chores or responsibilities at home?*
- 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 let your child know when they are being good?*
- Yes
- No
Does your child have problems dealing with angry feelings?*
- Yes
- No
Do you help your child control their anger?*
- Yes
- No
School
Did your child attend a preschool program?*
- Yes
- No
Has your child started elementary school?*
- Yes
- No
Do you have any concerns about your child’s school experience?*
- Yes
- No
- Not applicable
Are you able to attend activities or functions at your child’s school?*
- Yes
- No
- Not applicable
Is your child involved in after-school activities?*
- Yes
- No
- Not applicable
Does your child receive any special education services?*
- Yes
- No
Healthy Teeth
Does your child brush their teeth twice a day?*
- Yes
- No
Does your child see the dentist twice a year?*
- Yes
- No
Nutrition
Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.*
- Yes
- No
Does your child drink soda, juice, or other sugar-sweetened drinks?*
- Yes
- No
Does your child eat breakfast every day?*
- 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
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
Does your child have trouble going to sleep or do they wake up during the night?*
- Yes
- No
Does your child have a regular bedtime?*
- 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
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 street safety habits, such as stopping at the curb, looking both ways, and never crossing the street without a grown-up?*
- 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 have working smoke alarms installed on every level of your home?*
- Yes
- No
Do you have carbon monoxide detectors/alarms in your home?*
- Yes
- No
Do you have an emergency escape plan in case of a fire?*
- Yes
- No
Does your child know what to do if the fire alarm rings?*
- 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
- Unsure
Is the ammunition stored and locked up separately from the gun?*
- Yes
- No
- Unsure
Have you talked to your child about gun safety?*
- Yes
- No
Have you taught your child that it is never OK for an adult to tell a child to keep secrets from their parents?*
- Yes
- No
Does your child know that it is never OK for an older child or an adult to ask to see their private parts?*
- Yes
- No

BRIGHT FUTURE PHYSICAL-AGE 6

Bright Futures Physical Exam Pre-visit (6 years old)

Developmental Screening

Risk Assessment

Anemia

Dyslipidemia

Lead

Oral Health

Tuberculosis

Neighborhood and Family Violence (Bullying and Fighting)

Living Situation and Food Security

Alcohol and Drugs

Emotional Security and Self-Esteem

Connectedness with Family and Peers

Family Rules and Routines

School

Healthy Teeth

Nutrition

Physical Activity

Safety