Bright Futures 2 Years Old Physical- Parent

Bright Futures Physical Exam Pre-visit Form (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

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 elevated blood cholesterol level (240 mg/dL or higher) or who is taking cholesterol medication?*

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

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

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 FAMILY’S HEALTH AND WELL-BEING

Intimate Partner Violence

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 your child?*

Yes
No

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 your child?*

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

Taking Care of Yourself

Do you take time for yourself?*

Yes
No

Do you and your partner spend time alone together?*

Yes
No

Do you and your family do activities together?*

Yes
No

Do you have someone you can turn to if you need to talk about problems?*

Yes
No

YOUR CHILD’S BEHAVIOR

Is your child learning new things?*

Yes
No

Do you spend time alone with your child doing something that he likes to do?*

Yes
No

Do you encourage other family members and caregivers to be consistent, patient, and calm with your child?*

Yes
No

Do you show your child how to be physically active every day by playing and being active with her?*

Yes
No

Does your child play with other children?*

Yes
No

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

Hours

TALKING AND YOUR CHILD

Does your child have ways to tell you what he wants?*

Yes
No

Do you use simple words when asking your child a question or telling her what to do?*

Yes
No

Do you give your child plenty of time to respond?*

Yes
No

Do you sing songs and talk with your child about the things you do together?*

Yes
No

Do you read to your child or look at books together every day?*

Yes
No

TOILET TRAINING

Is your child interested in using the toilet?*

Yes
No

Does your child tell you when he has a bowel movement?*

Yes
No

Is your child dry for about 2 hours at a time?*

Yes
No

Does your child know the difference between being wet and dry?*

Yes
No

Do you help your child wash her hands after going to the bathroom?*

Yes
No

SAFETY

Car 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 vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?*

Yes
No

Outdoor Safety

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

Do you live near any backyard swimming pools, hot tubs, or spas?*

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