Bright Futures Physical Exam Pre-visit (4 years old)Child'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 tasks that your child is able to do.* Go to the bathroom and have a bowel movement by themselves Dress and undress without much help Play make-believe Answer questions such as “What do you do when you are cold?” and “When you are sleepy?” Use 4-word sentences Speak so strangers can understand 100% of what they say Draw pictures you recognize Follow simple rules when playing board or card games Tell you a story from a book Skip on one foot Climb stairs, using one foot, then the other, without support Draw a person with at least 3 body parts Draw a simple cross Unbutton and button medium-sized buttons Grasp a pencil with a thumb and fingers instead of her fist 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 (240mg/dL or higher) or who is taking cholesterol medication?* 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 Living Situation and Food SecurityIs permanent housing a worry for you?* Yes No Do you 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 did you 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 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 Safety in the CommunityDo you feel safe in your community?* Yes No Do you have someone you can turn to if you are concerned about your child’s safety?* Yes No Do you have connections to your community through faith groups, volunteer organizations, or recreational programs?* Yes No Do you spend time with parents of other children in your community?* Yes No Language Understanding and FluencyDoes your child clearly communicate his wants and needs to you and others?* Yes No Do you respond to your child’s questions with short and simple answers?* Yes No Do you give your child plenty of time to tell a story or answer a question?* Yes No Do you talk, sing, and read together every day?* Yes No FeelingsIs your child generally happy and active?* Yes No Do you help your child say “I’m sorry” for hurting others’ feelings?* Yes No Opportunities to Socialize With Other ChildrenIs your child interested in other children?* Yes No Does your child have a chance to play with other children in playgroups or at preschool?* Yes No Does your child have a best friend?* Yes No Do you praise your child when they are good or have finished a task?* Yes No Early Childhood Programs and PreschoolDoes your child attend preschool?* Yes No Are you happy with your child care or preschool arrangements?* Yes No Do you visit your child’s preschool and participate in activities there?* Yes No Readiness for SchoolDo you have any concerns about your child starting school in the coming year?* Yes No Are you doing things to get your child ready for preschool? This could include reading together and going to the library, the park, the zoo, and other places.* Yes No Eating Healthy: Nutritious FoodsDoes your child drink water every day?* Yes No How many ounces or milk does your child drink on most days?* Do you offer your child a variety of foods, including vegetables, fruits, and foods rich in protein, such a meat, eggs, chicken, or fish?* Yes No Is your child willing to try new flavors and food textures?* Yes No Do you let your child decide how much to eat and when to stop?* Yes No Daily Routines that Promote HealthDoes your child sleep well?* Yes No Do you have a regular bedtime and mealtime routines?* Yes No Do you brush your child’s teeth twice a day with a pea-sized amount of fluoridated toothpaste?* Yes No Promoting Physical Activity and Limiting TVHow much time every day does your child spend watching TV or using computers, tablets, or smartphones?* Does your child have a TV or an Internet-connected device in her bedroom?* 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 Are you physically active together as a family, such as going on walks or playing in the park?* Yes No Does your child play actively for at least 1 hour a day?* Yes No SafetyIs your child fastened securely in a car safety seat or belt-positioned booster 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 watch your child closely when she plays outside, especially near streets and driveways?* Yes No Are there swimming pools in your neighborhood?* Yes No Are you planning to have your child learn to swim?* Yes No Does your child always wear a US Coast Guard-approved life jacket when on a boat?* Yes No Does your child always use sunscreen when he plays outside?* Yes No Do you own a pet?* Yes No Have you taught your child how to behave around animals so she does not get bitten or scratched?* Yes No Does 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
