Bright Futures 12 month Physical-Parent – Child and Family Agency

Bright Futures Physical Exam Pre-visit Form (12 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

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 that was renovated in the past 6 months?*

Yes
No
Unsure

Oral Health

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

Living Situation and Food Security

Do you have enough heat, hot water, electricity, and working appliances in your home?*

Yes
No

Do you have problems with bugs, rodents, peeling paint or plaster, mold, or dampness?*

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

Social Connections With Family, Friends, Child Care, Home Visitation Program Staff, and Others

Do you have child care or an adult you trust to care for your child?*

Yes
No

Have you talked about your thoughts on feeding, sleeping, discipline, and media use with your caregiver?*

Yes
No

Do you participate in activities outside your home? These may be social, religious, volunteer, or recreational programs.*

Yes
No

CARING FOR YOUR CHILD

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

Yes
No

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

Yes
No

Do you have any questions about what to do when you become angry or frustrated with your child?*

Yes
No

Does your family regularly make time for reading, playing, and talking together?*

Yes
No

Do you eat together as a family?*

Yes
No

Do you have regular mealtimes and snack times?*

Yes
No

Do you help your child feel comfortable around new people and new situations?*

Yes
No

Do you have regular nap time and bedtime routines for your child, such as reading books and brushing teeth?*

Yes
No

Does your child watch TV or play on a tablet or smartphone?*

Yes
No

If Yes. how much time each day? (Hours)

Have you made a family media use plan to help you balance media use with other family activities?*

Yes
No

FEEDING YOUR CHILD

Does your child try feeding herself using a spoon?*

Yes
No

Does your child drink from a cup?*

Yes
No

Do you give your child small, hard foods such as peanuts and popcorn?*

Yes
No

Do you give your child round foods such as hot dogs, raw carrots, grapes, and grape tomatoes?*

Yes
No

Do you include your child in family meals?*

Yes
No

Have you begun to serve your child cow’s milk?*

Yes
No

Does your child eat vegetables and fruits?*

Yes
No

Does your child eat foods rich in protein, such as eggs, lean meat, chicken, or fish?*

Yes
No

Do you let your child decide what and how much to eat?*

Yes
No

HEALTHY TEETH

Do you brush your child’s teeth with a smear of fluoridated toothpaste 2 times a day using a soft toothbrush?*

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

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

Yes
No

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

Yes
No

Is the mattress in your child’s crib set on the lowest setting to prevent falls?*

Yes
No

Do you keep household cleaners, chemicals, and medicines locked up and out of your child’s sight and reach?*

Yes
No

Do all your electrical outlets have covers?*

Yes
No

Do you keep sharp objects, plastic bags, and electrical or drapery cords out of your child’s reach?*

Yes
No

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

Yes
No

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

Yes
No

Water and Sun Safety

Do you always stay within arm’s reach of your child when he is in the bath?*

Yes
No

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

Yes
No

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

Yes
No

Pets

Do you own a pet?*

Yes
No

If so, does your child interact with the pet?*

Yes
No
NA