Bright Futures Physical Exam Pre-visit Form (12 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.* Look for hidden objects. Imitate new gestures. Say, “Dad” or “Mom” with meaning Use one word other than Mom, Dad, or personal names. Follow a verbal command that includes a gesture. Take first independent steps. Stand without support. Drop objects in a cup. Pick up small object with 2-finger pincer grasp. Pick up food and eat it. RISK ASSESSMENT 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 that was renovated in the past 6 months?* Yes No Unsure Oral HealthDoes 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-BEINGLiving Situation and Food SecurityDo you have enough heat, hot water, electricity, and working appliances in your home?* Yes No Do you have problems with bugs, rodents, peeling paint or plaster, mold, or dampness?* 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 Social Connections With Family, Friends, Child Care, Home Visitation Program Staff, and OthersDo you have child care or an adult you trust to care for your child?* Yes No Have you talked about your thoughts on feeding, sleeping, discipline, and media use with your caregiver?* Yes No Do you participate in activities outside your home? These may be social, religious, volunteer, or recreational programs.* Yes No CARING FOR YOUR CHILDIf your child is upset, do you help distract him using another activity, book, or toy?* Yes No Do you use time-outs as a way to manage your child’s behavior?* Yes No Do you have any questions about what to do when you become angry or frustrated with your child?* Yes No Does your family regularly make time for reading, playing, and talking together?* Yes No Do you eat together as a family?* Yes No Do you have regular mealtimes and snack times?* Yes No Do you help your child feel comfortable around new people and new situations?* Yes No Do you have regular nap time and bedtime routines for your child, such as reading books and brushing teeth?* Yes No Does your child watch TV or play on a tablet or smartphone?* Yes No 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 FEEDING YOUR CHILDDoes your child try feeding herself using a spoon?* Yes No Does your child drink from a cup?* Yes No Do you give your child small, hard foods such as peanuts and popcorn?* Yes No Do you give your child round foods such as hot dogs, raw carrots, grapes, and grape tomatoes?* Yes No Do you include your child in family meals?* Yes No Have you begun to serve your child cow’s milk?* Yes No Does your child eat vegetables and fruits?* Yes No Does your child eat foods rich in protein, such as eggs, lean meat, chicken, or fish?* Yes No Do you let your child decide what and how much to eat?* Yes No HEALTHY TEETHDo you brush your child’s teeth with a smear of fluoridated toothpaste 2 times a day using a soft toothbrush?* 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 Are you having any problems using your car safety seat?* Yes No Do you have a gate at the top and bottom of all stairs in your home?* Yes No Is the mattress in your child’s crib set on the lowest setting to prevent falls?* Yes No Do you keep household cleaners, chemicals, and medicines locked up and out of your child’s sight and reach?* Yes No Do all your electrical outlets have covers?* Yes No Do you keep sharp objects, plastic bags, and electrical or drapery cords out of your child’s reach?* Yes No Do you keep your child away from the stove, fireplaces, and space heaters?* Yes No Are your TVs, bookcases, and dressers secured to the wall so they cannot fall over and hurt your child?* Yes No Water and Sun SafetyDo you always stay within arm’s reach of your child when he is in the bath?* Yes No Do you have a swimming pool, pond, or lake in or near your home?* Yes No Do you put a hat on your child and apply sunscreen on her when you go outside?* Yes No PetsDo you own a pet?* Yes No If so, does your child interact with the pet?* Yes No NA
