Bright Futures Physical Exam Pre-visit Form (6 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.* Pat or smile at his reflection. Look when you call her name. Babble. Roll over from his back to his tummy. Sit briefly without support. Make sounds such as “ga,” “ma,” and “ba.” Pass a toy from one hand to another Rake small objects with 4 fingers. Bang small objects on a surface. 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 TuberculosisWas your baby 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 baby had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?* Yes No Unsure Is your baby infected with HIV?* 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-BEINGLiving Situation and Food SecurityIs permanent housing a worry for you?* Yes No Do you have the things you need to take care of the baby, such as a crib, a car safety seat, and diapers?* Yes No Does your home have enough heat, hot water, electricity, and working appliances?* 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 you did not have money to get more?* Yes No Alcohol and DrugsDoes anyone in your household drink beer, wine, or liquor?* Yes No Do you or other family members use marijuana, cocaine, pain pills, narcotics, or other controlled substances?* Yes No Family Relationships and Support Do you have people you can go to when you need help with your family?* Yes No Do you have child care or a reliable person to care for your baby?* Yes No Your Baby’s DevelopmentIs your baby learning new things?* Yes No Is your baby adapting to new situations, people, and places?Is your baby adapting to new situations, people, and places?* Yes No Does your baby have ways to tell you what he wants and needs?* Yes No Does your baby respond when you look at books together?* 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) Does your baby have a regular daily schedule for feeding, napping, playing, and sleeping?* Yes No Is your baby learning to go to sleep by himself?* Yes No Can your baby calm herself?* Yes No Do you have ways to help your baby calm himself if he cannot do it himself?* Yes No Do you give your baby a bottle in her crib?* Yes No FEEDING YOUR BABYWhat are you feeding your baby? Select All Breast Milk Formula Both Are you feeding your baby any drinks or foods besides breast milk or formula? Select All Water Juice Cereal Meats Fruits Vegetables Other foods Does your baby let you know when he likes or dislikes new foods that you have introduced?* Yes No Do you wash vegetables and fruits before serving them to your baby and family?* Yes No If you are breastfeeding, answer these questions.Are you planning on continuing? Yes No N/A Do you have questions about pumping and storing your breast milk? Yes No Are you still giving your baby vitamin D drops and iron drops? Yes No If you are formula feeding, or providing formula a supplementation, answer these questions.Are you using iron-fortified formula? Yes No Do you have any questions or concerns about the formula, such as how much it costs or how to prepare it? Yes No SAFETYIs your baby fastened securely in a rear-facing car safety seat in the back seat every time she rides in a vehicle?* Yes No Are you having any problems with your car safety seat?* Yes No Is your water heater set so the temperature at the faucet is at or below 120°F/49°C?* Yes No Do you have barriers around space heaters, woodstoves, and kerosene heaters?* Yes No Do you put a hat on your baby and apply sunscreen on her when you go outside?* Yes No Do you keep household cleaners, chemicals, 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 he is in the bath?* Yes No Do you always keep one hand on your baby when changing diapers or clothing on a changing table, couch, or bed?* Yes No Do you have a gate at the top and bottom of all stairs in your home?* Yes No Do you continue to place your baby onto her back for sleep?* Yes No Does your baby sleep in a crib?* Yes No
