Forms – Bright Futures Physical 5yrs – Child and Family Agency

Bright Futures Physical Exam Pre-visit (5 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

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

Neighborhood and Family Violence (Bullying and Fighting)

Are there frequent reports of violence in your community or school?*

Yes
No

Has your child ever been bullied or hurt physically by someone?*

Yes
No

Has your child every bullied or been aggressive with others?*

Yes
No

Living Situation and Food Security

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

Is there anyone in your child’s life whose alcohol or drug use concerns you?*

Yes
No

Emotional Security and Self-Esteem

Does your child usually seem happy?*

Yes
No

Are there things your child is really good at doing or is proud of?*

Yes
No

Connectedness with Family and Peers

Does your family get along well with each other?*

Yes
No

Does your family do things together?*

Yes
No

Family Rules and Routines

Does your child have chores or responsibilities at home?*

Yes
No

Do you have clear rules and expectations for your child?*

Yes
No

When your child breaks the rules, are you consistent with consequences and discipline?*

Yes
No

Do you let your child know when they are being good?*

Yes
No

Does your child have problems dealing with angry feelings?*

Yes
No

Do you help your child control their anger?*

Yes
No

School

Did your child attend a preschool program?*

Yes
No

Has your child started elementary school?*

Yes
No

Do you have any concerns about your child’s school experience?*

Yes
No
Not applicable

Are you able to attend activities or functions at your child’s school?*

Yes
No
Not applicable

Is your child involved in after-school activities?*

Yes
No
Not applicable

Does your child receive any special education services?*

Yes
No

Healthy Teeth

Does your child brush their teeth twice a day?*

Yes
No

Does your child see the dentist twice a year?*

Yes
No

Nutrition

Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.?*

Yes
No

Does your child drink soda, juice, or other sugar-sweetened drinks?*

Yes
No

Does your child eat breakfast every day?*

Yes
No

Physical Activity

Is your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.*

Yes
No

How much time every day does your child spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting schoolwork)?*

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

Does your child have trouble going to sleep or do they wake up during the night?*

Yes
No

Does your child have a regular bedtime?*

Yes
No

Safety

Is your child fastened securely in a car safety seat or belt-positioned booster 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

Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?*

Yes
No

Does your child know street safety habits, such as stopping at the curb, looking both ways, and never crossing the street without a grown-up?*

Yes
No

Does your child know how to swim?*

Yes
No

Does your child know to always have an adult watching them in the water and never to swim alone?*

Yes
No

Does your child always use sunscreen when playing outside?*

Yes
No

Do you have working smoke alarms installed on every level of your home?*

Yes
No

Do you have carbon monoxide detectors/alarms in your home?*

Yes
No

Do you have an emergency escape plan?*

Yes
No

Does your child know what to do if the fire alarm rings?*

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

Have you talked to your child about gun safety?*

Yes
No

Have you taught your child that it is never OK for an adult to tell a child to keep secrets from their parents?*

Yes
No

Does your child know that it is never OK for an older child or an adult to ask to see their private parts?*

Yes
No