Bright Futures Physical Exam Pre-visit Form (18 Month Visit) for ParentsChild'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 task that your child is able to do.* Engage with others for play. Help dress and undress himself. Point to pictures in a book. Point to an interesting object to draw your attention to it. Turn and look at an adult if something new happens. Begin to scoop with a spoon. Use words to ask for help. Identify at least 2 body parts. Name at least 5 familiar objects, such as ball or milk. Walk up with 2 feet per step with his hand held. Sit in a small chair. Carry a toy while walking. Scribble spontaneously. Throw a small ball a few feet while standing. 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 VisionDo you have concerns about how your child sees?* Yes No Unsure Do your child’s eyes appear unusual or seem to cross?* Yes No Unsure Do your child’s eyelids droop or does one eyelid tend to close?* Yes No Unsure Have your child’s eyes ever been injured?* Yes No Unsure ANTICIPATORY GUIDANCEYOUR CHILD’S BEHAVIOR Do you praise your child for good behavior?* Yes No If your child is upset, do you help distract him with another activity, book, or toy?* Yes No Do other caregivers set the same limits for your child as you do?* Yes No Do you use time-outs as a way to manage your child’s behavior?* Yes No Have you thought about toilet training?* Yes No If you are planning to have another baby, have you thought about how you will prepare your child?* Yes No NA TALKING AND COMMUNICATINGDo you read, sing, and talk with your child about what you are seeing and doing?* Yes No Does he wave “bye-bye”?* Yes No Do you use simple words to tell your child what to do?* Yes No YOUR CHILD AND TV How much time every day does your child spend watching TV or using computers, tablets, or smartphones?* HoursIf your child uses media, do you monitor the shows your child watches or activity she does?* Yes No HEALTHY EATINGDo you provide a variety of vegetables, fruits, and other nutritious foods?* Yes No Does your child eat much food that you would describe as junk food?* Yes No Does your child drink water every day?* Yes No Is your child willing to try new foods?* Yes No SAFETYCar and Home SafetyIs your child fastened securely in a rear-facing car safety seat in the back seat every time he rides in a vehicle?* Yes No Does everyone in the car always use a lap and shoulder seat belt, booster seat, or car safety seat?* Yes No Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?* Yes No Do you keep cigarettes, lighters, matches, and alcohol out of your child’s sight and reach?* Yes No Do you keep your child away from the stove, fireplaces, and space heaters?* Yes No Do you have a gate at the top and bottom of all stairs in your home?* Yes No Do you keep furniture away from windows and use operable window guards on windows on the second floor and higher? (Operable means that, in case of an emergency, an adult can open the window.)* Yes No Are your TVs, bookcases, and dressers secured to the wall so they cannot fall over and hurt your child?* Yes No Do you have any questions about other ways to keep your home safe?* Yes No Sun ProtectionDo you apply sunscreen on your child whenever she plays outside?* Yes No Gun SafetyDoes anyone in your home or the homes where your child spends time have a gun?* Yes No If yes, is the gun unloaded and locked up?* Yes No If yes, is the ammunition stored and locked up separately from the gun?* Yes No
