Bright Futures Physical Exam Pre-visit Form (9 Month Visit) for ParentsPatient's 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 baby?Does your baby have special health care needs?Have there been major changes lately in your baby's or family’s life?Have any of your baby's relatives developed new medical problems since your last visit?Does your baby live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?Do you have specific concerns about your baby's development, learning, or behavior?Developmental ScreeningCheck off each of the task that your baby is able to do.* Use basic gestures, such as holding her arms out to be picked up or waving “bye-bye.” Look for dropped objects. Play games such as peekaboo and pat-a-cake. Turn consistently when his name is called. Say, “Dada” or “Mama.” Look around when you say things such as “Where’s your bottle?” and “Where’s your blanket?” Copy sounds that you make. Sit well without support. Pull herself to a standing position. Move easily between sitting and lying. Crawl on hands and knees. Pick up food and eat it. Pick up small objects with 3 fingers and a thumb. Let go of objects on purpose. Bang objects together. RISK ASSESSMENT HearingDo you have concerns about how your baby hears?* Yes No Unsure LeadDoes your baby 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 that was renovated in the past 6 months?* Yes No Unsure Oral HealthDoes your baby’s primary water source contain fluoride?* Yes No Unsure VisionDo you have concerns about how your baby sees?* Yes No Unsure Do your baby’s eyes appear unusual or seem to cross?* Yes No Unsure Do your baby’s eyelids droop or does one eyelid tend to close?* Yes No Unsure Have your baby’s eyes ever been injured?* Yes No Unsure ANTICIPATORY GUIDANCEYOUR FAMILY’S HEALTH AND WELL-BEING Do you always feel safe in your home?* Yes No Has your partner, or another significant person in your life, ever hit, kicked, or shoved you, or physically hurt you or the baby?* Yes No Have you developed routines or other ways to take care of yourself?* Yes No CARING FOR YOUR BABYDo you have a regular bedtime routine for your baby?* Yes No Does she wake up during the night?* Yes No Is your baby learning new things?* Yes No Does your baby have ways to tell you what he wants and needs?* Yes No Is a TV, computer, tablet, or smartphone on in the background while your baby is in the room?* Yes No Does your baby watch TV or play on a tablet or smartphone? If yes, how much time each day? (Hours) Have you made a family media use plan to help you balance media use with other family activities?* Yes No DISCIPLINE Do you and your partner agree on how to handle your baby’s behavior?* Yes No Do you limit the use of “No” to only the most important issues?* Yes No If you have other children, do you let them help with the baby as much as they can?* Yes No NA FEEDING YOUR BABYDoes your baby feed herself?* Yes No Does your baby drink from a cup?* Yes No Do you let your baby decide what and how much to eat?* Yes No Do you give your baby foods with different textures (such as pureed, blended, mashed, chopped, or lumps)?* Yes No If you are breastfeeding, are you planning on continuing?* Yes No NA Car and Home SafetyIs your baby fastened securely in a rear-facing car safety seat in the back seat every time he rides in a vehicle?* Yes No Do you have any habits or reminders that prevent you from ever leaving your baby in the car?* Yes No Do you keep your baby away from the stove, fireplaces, and space heaters?* Yes No Do you keep cleaners and medicines locked up and out of your baby’s sight and reach?* Yes No Do you always stay within arm’s reach of your baby when she is in the bathtub?* Yes No Do you keep furniture away from windows and use operable window guards on second-floor and higher windows? (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 Gun SafetyDoes anyone in your home or the homes where your baby 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
