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Forms – Bright Futures Physical 18+
Patient's Name
*
First
Last
Patient's Date of Birth
*
MM slash DD slash YYYY
Today's Date
*
MM slash DD slash YYYY
Please answer the following questions to the best of your ability. Note that all answers will remain confidential unless you report that someone is hurting you, or that you plan to hurt yourself or someone else.
Do you have any concerns, questions, or problems that you would like to discuss?
What are you most proud of about yourself?
Do you have special health care needs?
Have there been major changes lately in your family’s life?
Have any of your relatives developed new medical problems since your last visit?
Do you live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
Developmental Screening
Check off each of the items that you feel are true for you.
*
I do things that help me have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping myself safe.
I have at least one adult in my life who I know I can go to if I need help.
I have a friend or a group of friends that I feel comfortable to be around.
I help others.
I am able to bounce back when life doesn’t go my way.
I feel hopeful and confident.
I am becoming more independent and I make more of my own decisions.
Risk Assessment
Anemia
Does your diet include iron rich foods, such as meat, iron-fortified cereals, or beans?
*
Yes
No
Unsure
Do you eat a vegetarian diet (do not eat red meat, chicken, fish, or seafood)?
*
Yes
No
Unsure
If you are a vegetarian, do you take an iron supplement?
*
Yes
No
Unsure
Have you ever been diagnosed with iron deficiency anemia?
*
Yes
No
Unsure
Do you or your family ever struggle to put food on the table?
*
Yes
No
Unsure
For females: Do you have excessive menstrual bleeding or other blood loss?
*
Yes
No
Unsure
Not applicable
For females: Does your period last more than 5 days?
*
Yes
No
Unsure
Not applicable
Dyslipidemia
Do you have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (males) or 65 (females)?
*
Yes
No
Unsure
Do you have a parent with an elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?
*
Yes
No
Unsure
Do you smoke cigarettes or use e-cigarettes?
*
Yes
No
Unsure
Sexually Transmitted infections/HIV
Have you ever had sex, including intercourse or oral sex?
*
Yes
No
Are you having unprotected sex?
*
Yes
No
Are you having sex with multiple partners or anonymous partners?
*
Yes
No
Are you or any of your past or current sexual partners bisexual?
*
Yes
No
Unsure
Have you ever been treated for a sexually transmitted infection?
*
Yes
No
Have any of your past or current sex partners been infected with HIV or use injection drugs?
*
Yes
No
Unsure
Do you trade sex for money or drugs or have sex partners who do?
*
Yes
No
Unsure
For males: Have you ever had sex with other males?
*
Yes
No
Not Applicable
Do you now use or have you ever used injection drugs?
*
Yes
No
Tuberculosis
Were you 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
Have you had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
*
Yes
No
Unsure
Are you infected with HIV?
*
Yes
No
Unsure
Vision
Have you ever failed a school vision screening test?
*
Yes
No
Unsure
Do you have concerns about your vision?
*
Yes
No
Unsure
Do you have trouble with near or far vision?
*
Yes
No
Unsure
Do you tend to squint?
*
Yes
No
Unsure
Healthy Teen
Do you brush your teeth twice a day?
*
Yes
No
Do you floss your teeth once a day?
*
Yes
No
Do you see the dentist regularly?
*
Yes
No
Do you have trouble accessing dental care?
*
Yes
No
Nutrition
Do you have any concerns about your weight?
*
Yes
No
Are you currently doing anything to try to gain or lose weight?
*
Yes
No
Do you have access to healthy food options at home and school?
*
Yes
No
Do you eat fruits and vegetables every day?
*
Yes
No
Do you have milk, yogurt, cheese, or other foods that contain calcium every day?
*
Yes
No
Do you drink juice, soda, sports drinks, or energy drinks?
*
Yes
No
Do you ever skip meals?
*
Yes
No
Do you eat meals together with your family?
*
Yes
No
Physical Activity and Sleep
Are you physically active at least 1 hour every day? This includes running, playing sports, or doing physically active things with friends.
*
Yes
No
How much time do you spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting work/school)?
*
Do you have a TV, computer, tablet, or smartphone in your bedroom?
*
Yes
No
Do you have a regular bedtime?
*
Yes
No
Do you have any trouble getting to sleep at night or waking up in the morning?
*
Yes
No
Living Situation and Food Security
Do you feel safe in your living situation?
*
Yes
No
Within the past 12 months, did you worry that 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
Transitioning to Adult Health Care
Do you feel confident about your ability to begin seeing an adult medical provider?
*
Yes
No
Do you have health insurance coverage?
*
Yes
No
Do you know your medical conditions, medications, allergies, and family history?
*
Yes
No
Interpersonal Violence
Do you get along with the people you live with?
*
Yes
No
Do you have ways that help you deal with feeling angry?
*
Yes
No
Have you been in a fight in the past 12 months?
*
Yes
No
Do you know anyone in a gang?
*
Yes
No
Do you belong to a gang?
*
Yes
No
Have you ever been hit, slapped, or physically hurt while on a date?
*
Yes
No
Have you ever been touched in a sexual way against your wishes or without your consent?
*
Yes
No
Have you ever been forced to have sexual intercourse?
*
Yes
No
Have you ever been in a relationship with a person who threatens you physically or hurts you?
*
Yes
No
Do you feel threatened by anyone?
*
Yes
No
Are you worried that you might ever hurt someone else?
*
Yes
No
Alcohol and Drugs
Is there anyone in your life whose tobacco, alcohol, or drug use concerns you?
*
Yes
No
Connectedness with Family, Peers, and Community
Do you have a close friend?
*
Yes
No
Do you get along with members of your family?
*
Yes
No
Do you have activities you like to do after school or work or on the weekends?
*
Yes
No
Do you help others out at home, at school, or in your community?
*
Yes
No
School
Have you graduated from high school or completed a GED?
*
Yes
No
Do you have plans for work or school?
*
Yes
No
Coping with Stress and Decision-Making
Do you feel really stressed out all the time?
*
Yes
No
Do you have strategies to reduce or relieve your stress?
*
Yes
No
Mood and Mental Health
Do you harm yourself, such as by cutting, hitting, or pinching yourself?
*
Yes
No
Do you have any questions about your gender identity?
*
Yes
No
Healthy Behavior Choices
If you have been in romantic relationships, have you always felt safe and respected?
*
Yes
No
Have you ever had sex, including oral, vaginal, or anal sex?
*
Yes
No
Have you had multiple partners in the past year?
*
Yes
No
Do you have both male and female partners?
*
Yes
No
Do you and your partner use condoms every time?
*
Yes
No
Do you and your partner always use another form of birth control along with a condom?
*
Yes
No
Are you aware of emergency contraception?
*
Yes
No
Do you smoke cigarettes or use e-cigarettes?
*
Yes
No
Do you chew tobacco or use other tobacco products?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Have you used drugs, including marijuana, street drugs, inhalants, or steroids?
*
Yes
No
Have you ever taken prescription drugs that were not given to you for a medical condition?
*
Yes
No
Safety
Do you use earplugs or noise-cancelling headphones to protect your hearing around loud noises or at concerts?
*
Yes
No
Do you often listen to loud music?
*
Yes
No
Do you always wear a lap and shoulder seat belt?
*
Yes
No
Do you wear a helmet to protect your head when you ride a bike, a skateboard, a motorcycle, or an ATV?
*
Yes
No
Do you ever use your phone or tablet while driving, even at stop signs?
*
Yes
No
Do you have someone you can call for a ride if you feel unsafe driving yourself or riding with someone else?
*
Yes
No
Do you use sunscreen?
*
Yes
No
Do you visit tanning parlors?
*
Yes
No
Do you have access to guns?
*
Yes
No
Have you carried a weapon to school or work?
*
Yes
No
