Bright Futures Physical Exam Pre-visit (5 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.* Is beginning to skip Walk on tiptoes when asked Catch a bounced ball with 2 hands Copy a triangle Draw a 6-part person Copy first name Cut well with scissors Spread with a knife Dress and undress without help Urinate and have a bowel movement on their own Is dry through the day Tell a story of 2 sentences or more Follow directions for 4 individual prepositions, such as “on”, “under”, “behind” and “in front of” Play and interact with peers Answer “why” questions Count 5 objects Name 3 or more single numbers Name 4 or more letters out of alphabetic order Write 2 or more letters 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 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 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 SecurityWithin 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 child’s life whose alcohol or drug use concerns you?* Yes No Emotional Security and Self-EsteemDoes 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 PeersDoes your family get along well with each other?* Yes No Does your family do things together?* Yes No Family Rules and RoutinesDoes 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 SchoolDid 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 TeethDoes your child brush their teeth twice a day?* Yes No Does your child see the dentist twice a year?* Yes No NutritionDo 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 ActivityIs 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 SafetyIs 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
