CBC Bright Futures Physical 15-17 yrs – Parent Bright Futures Physical Exam Pre-visit (15-17 years old) for ParentsPatient Name* First Last Patient'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 teen?Does your teen have special health care needs?Have there been major changes lately in your teen’s or family’s life?Have any of your teen’s relatives developed new medical problems since your last visit?Does your teen live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?Developmental ScreeningCheck off each of the items you feel are true for your teen.* My teen does things that help them have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping themselves safe My teen has at least one adult in their life who care about them and know they can go to if they need help My teen has at least one friend or a group of friends who they feel comfortable around My teen helps others by themselves or by working with a group in a school, a faith-based organization, or the community My teen is able to bounce back when things don’t go their way My teen feels hopeful and self-confident My teen is becoming more independent and making more decisions on their own as they get older Risk Assessment AnemiaDoes your teen’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?* Yes No Unsure Has your teen ever been diagnosed with iron deficiency anemia?* Yes No Unsure Does your family ever struggle to put food on the table?* Yes No Unsure If your teen is female, does she have excessive menstrual bleeding or other blood loss?* Yes No Unsure Not Applicable If your teen is female, does her period last more than 5 days?* Yes No Unsure Not Applicable DyslipidemiaDoes your teen 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 Does your teen have a parent with an elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?* Yes No Unsure HearingDo you have concerns about how your teen hears?* Yes No Unsure Oral HealthDoes your teen have a dentist?* Yes No Unsure Does your teen’s primary water source contain fluoride?* Yes No Unsure Sexually Transmitted infections/HIVTeens who are sexually active are at risk of sexually transmitted infection, including HIV. Teens who use injection drugs are at risk of HIV. Are you concerned that your teen might be at risk?* Yes No Unsure TuberculosisWas your teen 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 teen had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?* Yes No Unsure Is your teen infected with HIV?* Yes No Unsure VisionDo you have concerns about how your teen sees?* Yes No Unsure Does your teen have trouble with near or far vision?* Yes No Unsure Has your teen ever failed a school vision screening test?* Yes No Unsure Does your teen tend to squint?* Yes No Unsure Healthy TeethDoes your teen brush and floss their teeth every day?* Yes No Does your teen see the dentist regularly?* Yes No Do you have trouble getting dental care?* Yes No NutritionDo you have any concerns about your teen’s weight, eating habits, or physical activity?* Yes No Does your teen talk about getting fat or dieting to lose weight?* Yes No Do you think your teen eats healthy foods?* Yes No Do you have any difficulty getting healthy food for your family?* Yes No Do you eat meals together as a family?* Yes No Physical Activity and SleepIs your teen physically active at least 1 hour every day? This includes running, playing sports, or doing physically active things with friends.* Yes No Are there opportunities to safely exercise outside in your neighborhood?* Yes No Do you and your teen participate in physical activities together?* Yes No How much time every day does your teen spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting schoolwork)?* Does your teen have a TV, computer, tablet, or smartphone in their 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 teen have a regular bedtime?* Yes No Do you think your teen gets enough sleep?* Yes No Interpersonal Violence (Bullying and Fighting)Are there frequent reports of violence in your community or school?* Yes No Is your teen involved in that violence?* Yes No Has your teen ever been threatened with physical harm or injured in a fight?* Yes No Has your teen bullied others?* Yes No Has your teen been suspended from school because of fighting, bullying, or carrying a weapon?* Yes No Do you know your teen’s friends and the activities they participate in or attend?* Yes No If your teen is in a relationship, is it respectful?* Yes No Would your teen tell you if someone pressured or forced her to have sex?* Yes No Living Situation and Food SecurityDo you have concerns about your living situation?* 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 DrugsIs there anyone in your teen’s life whose alcohol or drug use concerns you?* Yes No Connectedness with Family, Peers, and CommunityDo your family members get along well with each other?* Yes No Do you take time to talk with your teen every day?* Yes No Does your family do things together?* Yes No Does your teen have chores and responsibilities at home?* Yes No Do you have clear rules and expectations for your teen?* Yes No Does your teen have interests outside of school?* Yes No Does your teen help others at home, in school, or in your community?* Yes No SchoolDoes your teen get to school on time?* Yes No Does your teen attend school almost every day?* Yes No Do you recognize your teen’s successes and support their efforts?* Yes No Does your teen have plans for after high school?* Yes No Coping with Stress and Decision-MakingHave you discussed with your teen ways to deal with stress?* Yes No Do you help your teen make decisions or solve problems?* Yes No Mood and Mental HealthIs your teen frequently irritable?* Yes No Have you noticed changes in your teen’s weight, sleep habits, or behaviors?* Yes No Do you have concerns about your teen’s emotional health, such as being frequently sad or depressed?* Yes No Do you think your teen worries too much or appears overly anxious?* Yes No Healthy Behavior ChoicesHave you talked with your teen about relationships, dating, and sex?* Yes No Have you talked with your teen about their sexuality?* Yes No Do you have house rules about curfews, dating, and friends?* Yes No Are you worried about sexual pressures on your teen?* Yes No Have you talked with your teen and alcohol and drug use?* Yes No To your knowledge, is your teen currently using alcohol or drugs, or have they used them in the past?* Yes No Have you discussed consequences if you discover your teen is using tobacco/nicotine, alcohol, or drugs?* Yes No Do you know where your teen’s friends are and what they’re doing?* Yes No SafetyDoes your teen always wear a lap and shoulder seat belt and bicycle helmet?* Yes No Do you have rules or restrictions around driving?* Yes No Does your teen use sunscreen?* Yes No Does your teen often listen to loud music?* Yes No Is there a gun in your home or the homes where your teen visits?* 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 with your teen about gun safety?* Yes No
