Bright Futures Physical 6 Month-Parents – Child and Family Agency

Bright Futures Physical Exam Pre-visit Form (6 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.*

Pat or smile at his reflection.
Look when you call her name.
Babble.
Roll over from his back to his tummy.
Sit briefly without support.
Make sounds such as “ga,” “ma,” and “ba.”
Pass a toy from one hand to another
Rake small objects with 4 fingers.
Bang small objects on a surface.

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

Tuberculosis

Was your baby 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 baby had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?*

Yes
No
Unsure

Is your baby infected with HIV?*

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

Living Situation and Food Security

Is permanent housing a worry for you?*

Yes
No

Do you have the things you need to take care of the baby, such as a crib, a car safety seat, and diapers?*

Yes
No

Does your home have enough heat, hot water, electricity, and working appliances?*

Yes
No

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 you did not have money to get more?*

Yes
No

Alcohol and Drugs

Does anyone in your household drink beer, wine, or liquor?*

Yes
No

Do you or other family members use marijuana, cocaine, pain pills, narcotics, or other controlled substances?*

Yes
No

Family Relationships and Support

Do you have people you can go to when you need help with your family?*

Yes
No

Do you have child care or a reliable person to care for your baby?*

Yes
No

Your Baby’s Development

Is your baby learning new things?*

Yes
No

Is your baby adapting to new situations, people, and places?Is your baby adapting to new situations, people, and places?*

Yes
No

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

Yes
No

Does your baby respond when you look at books together?*

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)

Does your baby have a regular daily schedule for feeding, napping, playing, and sleeping?*

Yes
No

Is your baby learning to go to sleep by himself?*

Yes
No

Can your baby calm herself?*

Yes
No

Do you have ways to help your baby calm himself if he cannot do it himself?*

Yes
No

Do you give your baby a bottle in her crib?*

Yes
No

FEEDING YOUR BABY

What are you feeding your baby?

Select All
Breast Milk
Formula
Both

Are you feeding your baby any drinks or foods besides breast milk or formula?

Select All
Water
Juice
Cereal
Meats
Fruits
Vegetables
Other foods

Does your baby let you know when he likes or dislikes new foods that you have introduced?*

Yes
No

Do you wash vegetables and fruits before serving them to your baby and family?*

Yes
No

If you are breastfeeding, answer these questions.

Are you planning on continuing?

Yes
No
N/A

Do you have questions about pumping and storing your breast milk?

Yes
No

Are you still giving your baby vitamin D drops and iron drops?

Yes
No

If you are formula feeding, or providing formula a supplementation, answer these questions.

Are you using iron-fortified formula?

Yes
No

Do you have any questions or concerns about the formula, such as how much it costs or how to prepare it?

Yes
No

SAFETY

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

Yes
No

Are you having any problems with your car safety seat?*

Yes
No

Is your water heater set so the temperature at the faucet is at or below 120°F/49°C?*

Yes
No

Do you have barriers around space heaters, woodstoves, and kerosene heaters?*

Yes
No

Do you put a hat on your baby and apply sunscreen on her when you go outside?*

Yes
No

Do you keep household cleaners, chemicals, 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 he is in the bath?*

Yes
No

Do you always keep one hand on your baby when changing diapers or clothing on a changing table, couch, or bed?*

Yes
No

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

Yes
No

Do you continue to place your baby onto her back for sleep?*

Yes
No

Does your baby sleep in a crib?*

Yes
No