Bright Futures Physical Exam Pre-visit Form (2 1/2 Year 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.* Urinate in a potty or toilet. Poke food with a fork. Wash and dry hands. Play pretend with toys or dolls. Ask you to watch by saying, “Look at me!” Use pronouns, such as “me,” “his,” and “our,” correctly. Explain the reasons for things, such as needing a sweater when it’s cold. Name at least one color. Walk up steps, using one foot, then the other. Run well without falling. Copy a vertical line. Grasp a crayon with thumb and fingers instead of fist. Catch large balls. 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 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 Does your child have trouble with near or far vision?* 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 Family RoutineDoes your family eat meals together?* Yes No Do you have a regular bedtime routine for your child?* Yes No Do you encourage family exercise, such as walking, swimming, dancing, or bicycling?* Yes No Does your family go to museums, zoos, and other educational places together?* Yes No Do you and your partner participate in social activities? Do you do things with friends, away from the family?* Yes No Does everyone in your family follow the same routines and set the same limits for your child?* Yes No Learning To Talk And CommunicateDo you read to your child every day?* Yes No Do you use simple words when asking your child a question and give plenty of time for her to respond?* Yes No Do you carefully listen to your child and, if necessary, offer the right words to help him make sure he is understood?* Yes No Does your child become frustrated when others cannot understand what he says?* Yes No Getting Along With OthersDoes your child play with other children?* Yes No Do you allow your child to make choices such as what clothes to wear, what to eat, and what books to read?* Yes No 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 Has your family made a media use plan to help everyone balance time spent on media with other family and personal activities?* Yes No Getting Ready For PreschoolDo you have plans for child care or preschool in the next year?* Yes No Is your child a part of a regular playgroup?* Yes No Do you read books to your child about getting ready for school?* Yes No Are you encouraging toilet training?* Yes No Do you praise your child when she tries to use the potty?* Yes No SafetyCar and Home SafetyIs your child fastened securely in a car safety 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 Do you have a working smoke detector on every level of your home?* Yes No Do you test the batteries once a month?* Yes No Do you have an emergency escape plan in case of a fire?* Yes No Do you keep matches out of your child’s sight and reach?* Yes No Do you keep your child away from the stove, grills, fireplaces, and space heaters?* Yes No Outdoor SafetyWhen your child plays outside, do you make sure that he stays within fences and gates?* Yes No Does your child always wear a bike helmet when she rides on a tricycle, in a towed bike trailer, or in a seat on an adult’s bicycle?* Yes No Do you keep your child away from moving machines, lawn mowers, driveways, and streets?* Yes No Have you taught your child to be careful around dogs, especially if they are eating or you don’t know them?* Yes No Do you have a swimming pool, pond, or lake near your home?* Yes No Do you always put sunscreen on your child when she plays outside?* Yes No
