Bright Futures Physical Exam Pre-visit Form (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.* Play with other children and express interest in their play. Take off some clothing. Scoop well with a spoon. Use 50 words. Combine 2 words into a short phrase or sentence. Follow a 2-step command (such as “Pick it up and put it away”). Name at least 5 body parts. Speak so strangers can understand 50% of what he says. Kick a ball. Jump off the ground with 2 feet Run with coordination. Climb up a ladder at a playground. Stack objects. Turn book pages. Use his hands to turn objects. Draw lines. 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 DyslipidemiaDoes your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (male) or 65 (female)?* Yes No Unsure Does your child have a parent with elevated blood cholesterol level (240 mg/dL or higher) or who is taking cholesterol medication?* 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 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 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 GUIDANCEYOUR FAMILY’S HEALTH AND WELL-BEING Intimate Partner ViolenceDo 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 your child?* Yes No Living Situation and Food SecurityIs permanent housing a worry for you?* Yes No Do you have the things you need to take care of your child?* 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 Taking Care of YourselfDo you take time for yourself?* Yes No Do you and your partner spend time alone together?* Yes No Do you and your family do activities together?* Yes No Do you have someone you can turn to if you need to talk about problems?* Yes No YOUR CHILD’S BEHAVIORIs your child learning new things?* Yes No Do you spend time alone with your child doing something that he likes to do?* Yes No Do you encourage other family members and caregivers to be consistent, patient, and calm with your child?* Yes No Do you show your child how to be physically active every day by playing and being active with her?* Yes No Does your child play with other children?* Yes No How much time every day does your child spend watching TV or using computers, tablets, or smartphones?* HoursTALKING AND YOUR CHILDDoes your child have ways to tell you what he wants?* Yes No Do you use simple words when asking your child a question or telling her what to do?* Yes No Do you give your child plenty of time to respond?* Yes No Do you sing songs and talk with your child about the things you do together?* Yes No Do you read to your child or look at books together every day?* Yes No TOILET TRAININGIs your child interested in using the toilet?* Yes No Does your child tell you when he has a bowel movement?* Yes No Is your child dry for about 2 hours at a time?* Yes No Does your child know the difference between being wet and dry?* Yes No Do you help your child wash her hands after going to the bathroom?* Yes No SAFETYCar 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 vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?* Yes No Outdoor SafetyDoes 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 Do you live near any backyard swimming pools, hot tubs, or spas?* Yes No Gun SafetyDoes anyone in your home or the homes where your child 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
