Bright Futures 2 1/2 Years Old Physical-Parent

Bright Futures Physical Exam Pre-visit Form (2 1/2 Year 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

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

Does your child have trouble with near or far vision?*

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

Family Routine

Does your family eat meals together?*

Yes
No

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

Yes
No

Do you encourage family exercise, such as walking, swimming, dancing, or bicycling?*

Yes
No

Does your family go to museums, zoos, and other educational places together?*

Yes
No

Do you and your partner participate in social activities? Do you do things with friends, away from the family?*

Yes
No

Does everyone in your family follow the same routines and set the same limits for your child?*

Yes
No

Learning To Talk And Communicate

Do you read to your child every day?*

Yes
No

Do you use simple words when asking your child a question and give plenty of time for her to respond?*

Yes
No

Do you carefully listen to your child and, if necessary, offer the right words to help him make sure he is understood?*

Yes
No

Does your child become frustrated when others cannot understand what he says?*

Yes
No

Getting Along With Others

Does your child play with other children?*

Yes
No

Do you allow your child to make choices such as what clothes to wear, what to eat, and what books to read?*

Yes
No

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

Has your family made a media use plan to help everyone balance time spent on media with other family and personal activities?*

Yes
No

Getting Ready For Preschool

Do you have plans for child care or preschool in the next year?*

Yes
No

Is your child a part of a regular playgroup?*

Yes
No

Do you read books to your child about getting ready for school?*

Yes
No

Are you encouraging toilet training?*

Yes
No

Do you praise your child when she tries to use the potty?*

Yes
No

Safety

Car and Home Safety

Is your child fastened securely in a car safety 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

Do you have a working smoke detector on every level of your home?*

Yes
No

Do you test the batteries once a month?*

Yes
No

Do you have an emergency escape plan in case of a fire?*

Yes
No

Do you keep matches out of your child’s sight and reach?*

Yes
No

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

Yes
No

Outdoor Safety

When your child plays outside, do you make sure that he stays within fences and gates?*

Yes
No

Does your child always wear a bike helmet when she rides on a tricycle, in a towed bike trailer, or in a seat on an adult’s bicycle?*

Yes
No

Do you keep your child away from moving machines, lawn mowers, driveways, and streets?*

Yes
No

Have you taught your child to be careful around dogs, especially if they are eating or you don’t know them?*

Yes
No

Do you have a swimming pool, pond, or lake near your home?*

Yes
No

Do you always put sunscreen on your child when she plays outside?*

Yes
No