Bright Futures Physical Exam Pre-visit Form (15 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.* Imitate scribbling. Drink from cup with little spilling. Point to ask for something or to get help. Look around when you say things such as “Where’s your ball?” and “Where’s your blanket?” Use 3 words other than names. Speak in sounds that seem like an unknown language. Follow directions that do not include a gesture. Squat to pick up objects. Crawl up a few steps. Run. Make marks with a crayon. Drop an object into and take the object out of a container. 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 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 GUIDANCETALKING AND FEELINGIs your child learning new things?* Yes No Does your child show any worries or fears when meeting new people?* Yes No Do you take time for yourself?* Yes No Do you spend time alone with your partner?* Yes No Does your child point to something he wants and then watch to see if you see what he’s doing?* Yes No Does she wave “bye-bye”?* Yes No NA Do you talk to, sing to, and look at books with your child every day?* Yes No NA SLEEP ROUTINES AND ISSUESDoes your child have a regular bedtime routine?* Yes No Does your child sleep well?* Yes No How many hours does your child sleep? DaytimeHow many hours does your child sleep? NighttimeDoes your child have a blanket, stuffed animal, or toy that he likes to sleep with?* Yes No Do you have a TV or an Internet-connected device in your child’s bedroom?* Yes No TANTRUMS AND DISCIPLINE Does your child have frequent tantrums?* Yes No If your child is upset, do you help distract her with another activity, book, or toy?* Yes No Do you set limits for your child?* Yes No Do other caregivers set the same limits for your child as you do?* Yes No Do you praise your child when he is being good?* Yes No Do you have any questions about what to do when you become angry or frustrated with your child?* Yes No HEALTHY TEETHHas your child been to a dentist?* Yes No Do you brush your child’s teeth with a smear of fluoridated toothpaste 2 times a day using a soft toothbrush?* Yes No Does your child use a bottle?* 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 keep cleaners and medicines locked up and out of your child’s sight and reach?* Yes No Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?* 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 Do you have a gate at the top and bottom of all stairs in your home?* 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?* Yes No Do you have working smoke alarms on every floor of your home?* Yes No Do you test the batteries once a month?* Yes No Do you have a fire escape plan?* Yes No
