Forms – Bright Futures Physical 3yrs – Child and Family Agency

Bright Futures Physical Exam Pre-visit (3 years old)

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 tasks 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

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

Living Situation and Food Security

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

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 did you 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

Positive Family Interactions

Are your family members loving and affectionate with one another?*

Yes
No

Do you praise your child when he is being good?*

Yes
No

Do you have ways to constructively handle anger and settle disputes in your family?*

Yes
No

Does everyone who cares for your child set the same limits for your child?*

Yes
No

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

Yes
No

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

Yes
No

Taking Care of Yourself

Do you take time for yourself?*

Yes
No

Do you feel you are able to balance family and work?*

Yes
No

Do you spend time alone with your partner?*

Yes
No
Not applicable

Playing with Siblings and Peers

Does your child engage in fantasy play with dolls, toy animals, or blocks?*

Yes
No

Do you spend time alone with your child doing things you both enjoy?*

Yes
No

Does your child have chances to play with other children (such as on playdates or at preschool)?*

Yes
No

When your child plays with other children, do you help them learn how to take turns?*

Yes
No

If you have other children, do they get along with each other?*

Yes
No
Not applicable

Are you expecting or thinking about having another child?*

Yes
No

Reading and Talking with your Child

Do you read, sing songs, or play word games with your child every day?*

Yes
No

When you are reading together, do you ask your child questions about the pictures or story in the book?*

Yes
No

Do you encourage your child to tell you about his day?*

Yes
No

Does your family speak more than one language at home?*

Yes
No

Eating Healthy: Nutritious Foods

Does your child drink water every day?*

Yes
No

How many ounces of milk does your child drink on most days?*

Do you offer your child a variety of foods, including vegetables, fruits, and foods rich in protein, such a meat, eggs, chicken, or fish?*

Yes
No

Is your child willing to try new flavors and food textures?*

Yes
No

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

Yes
No

Promoting Physical Activity and Limiting TV

Are you physically active together as a family, such as going on walks or playing in the park?*

Yes
No

Does your child play actively for at least 1 hour a day?*

Yes
No

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

Does your child have a TV or an Internet-connected device in her bedroom?*

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

Safety

Is your child buckled securely in a car safety seat in the back seat every time he rides in a vehicle?*

Yes
No

Do you have any problems with your car seat?*

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 cut foods such as grapes and hot dogs into small pieces to prevent choking?*

Yes
No

Does your child play in a driveway or close to the street?*

Yes
No

Do you keep furniture away from windows and use operable window guards on windows on the second floor and higher? (Operable mean that, in case of emergency, an adult can open the window)*

Yes
No

Are there swimming pools near your home?*

Yes
No

Do you always stay within arm’s reach of your child when he is in or near water?*

Yes
No

Does your child always wear a US Coast Guard-approved life jacket when on a boat?*

Yes
No

Do you own a pet?*

Yes
No

Have you taught your child how to behave around animals so she does not get bitten or scratched?*

Yes
No

Does anyone in your home or the homes where your child spends time have a gun?*

Yes
No

Is the gun unloaded and locked up?*

Yes
No

Is the ammunition stored and locked up separately from the gun?*

Yes
No