CBC Bright Futures Physical 3 years old – Parent Bright Futures Physical Exam Pre-visit (3 years old)Child's Name* First Last Child's Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY 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 ScreeningCheck off each of the tasks that your child is able to do.* Go to the bathroom and urinate by themselves Put on a coat, jacket, or shirt by themselves Eat by themselves Begin to play make-believe Play and share with others Use 3-word sentences Speak so strangers can understand 75% or what they say Tell you a story from a book or TV Compare things using words such as bigger and shorter Understand simple prepositions such as on or under Pedal a tricycle Climb on and off a couch Jump forward Draw a single circle Draw a person with head and one other body part Cut with child scissors Risk Assessment AnemiaDoes 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 HearingDo you have concerns about how your child hears?* Yes No Unsure Do you have concerns about how your child speaks?* Yes No Unsure LeadDoes 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 HealthDoes your child have a dentist?* Yes No Unsure Does your child’s primary water source contain fluoride?* Yes No Unsure TuberculosisWas 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 SecurityDo 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 DrugsDoes 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 InteractionsAre 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 YourselfDo 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 PeersDoes 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 ChildDo 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 FoodsDoes 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 TVAre 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 SafetyIs 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
