Bright Futures Physical Exam Pre-visit Form (11-14 year old) 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 items you feel are true for your child.* My child does things that help them have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping themselves safe My child has at least one adult in their life who care about them and know they can go to if they need help My child has at least one friend or a group of friends who they feel comfortable around My child helps others by themselves or by working with a group in a school, a faith-based organization, or the community My child is able to bounce back when things don’t go their way My child feels hopeful and self-confident My child is becoming more independent and making more decisions on their own as they get older Risk Assessment AnemiaDoes your child’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?* Yes No Unsure Has your child ever been diagnosed with iron deficiency anemia?* Yes No Unsure Does your family ever struggle to put food on the table?* Yes No Unsure If your child is female, does she have excessive menstrual bleeding or other blood loss?* Yes No Unsure Not Applicable If your child is female, does her period last more than 5 days?* Yes No Unsure Not Applicable DyslipidemiaDoes your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (males) or 65 (females)?* Yes No Unsure Does your child have a parent with an elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?* Yes No Unsure HearingDo you have concerns about how your child hears?* 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 Sexually Transmitted infections/HIVAdolescents who are sexually active are at risk of sexually transmitted infection, including HIV. Adolescents who use injection drugs are at risk of HIV. Are you concerned that your young adolescent might be at risk?* Yes No Unsure Adolescents who use injection drugs are at risk of HIV. Are you concerned that your young adolescent might be at risk?* 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 Does your child have trouble with near or far vision?* Yes No Unsure Has your child ever failed a school vision screening test?* Yes No Unsure Does you child tend to squint?* Yes No Unsure Healthy TeenDoes your child brush and floss their teeth every day?* Yes No Does your child see the dentist regularly?* Yes No Do you have trouble getting dental care?* Yes No NutritionDo you have any concerns about your child’s nutrition, weight, eating habits, or physical activity?* Yes No Does your child talk about getting fat or dieting to lose weight?* Yes No Do you think your child eats healthy foods?* Yes No Do you have any difficulty getting healthy food for your family?* Yes No Do you have any concerns about your child’s eating habits or nutrition?* Yes No Do you eat meals together as a family?* Yes No Physical Activity and SleepIs your child physically active at least 1 hour every day? This includes running, playing sports, or doing physically active things with friends.* Yes No Are there opportunities to safely play outside in your neighborhood?* Yes No Do you and your child participate in physical activities together?* Yes No How much time every day does your child spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting schoolwork)?* Does your child have a TV, computer, tablet, or smartphone in their 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 Does your child have a regular bedtime?* Yes No Interpersonal Violence (Bullying and Fighting)Are there frequent reports of violence in your community or school?* Yes No Is your child involved in any of the violence?* Yes No Do you think your child is safe in the neighborhood?* Yes No Has your child ever been injured in a fight?* Yes No Has your child been bullied or hurt by others?* Yes No Has your child bullied or been aggressive toward others?* Yes No Have you talked to your child about violence in dating situations and how to be safe?* Yes No Living Situation and Food SecurityDo you have concerns about your living situation?* Yes No Do you have enough heat, hot water, and electricity?* Yes No Do you have appliances that work?* Yes No Do you have problems with bugs, rodents, or peeling paint or plaster?* 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 DrugsIs there anyone in your child’s life whose alcohol or drug use concerns you?* Yes No Connectedness with Family, Peers, and CommunityDo your family members get along well with each other?* Yes No Do you take time to talk with your child every day?* Yes No Does your family do things together?* Yes No Does your child have chores and responsibilities at home?* Yes No Do you have clear rules and expectations for your child?* Yes No Do you let your child know when they do something good?* Yes No Does your child have interests outside of school?* Yes No Does your child help others at home, in school, or in your community?* Yes No SchoolIs your child getting to school on time?* Yes No Is your child having any problems at school?* Yes No Does your child complete homework on time?* Yes No Has your child missed more than 2 days of school in any month?* Yes No Coping with Stress and Decision-MakingDoes your child worry too much or appear overly anxious?* Yes No Have you discussed ways to deal with stress?* Yes No Do you help your child make decisions or solve problems?* Yes No Mood and Mental HealthIs your child frequently irritable?* Yes No Have you noticed changes in your child’s weight or sleep habits?* Yes No Do you and your child often have conflicts about what your culture expects for their behavior and how their friends behave?* Yes No Do you have any concerns about your child’s emotional health, such as being frequently sad or depressed?* Yes No Healthy Behavior ChoicesHave you and your child talked about how their body will change during puberty?* Yes No Do you have house rules about curfews, dating, and friends?* Yes No Have you and your child talked about sex?* Yes No Have you talked about ways to deal with any pressures to have sex?* Yes No Have you talked with your child and alcohol and drug use?* Yes No Do you know your child’s friends?* Yes No Do you know where your child is and what they do after school and on the weekends?* Yes No Do you have consequences for your child if you discover they are using tobacco/nicotine, alcohol, or drugs?* Yes No To your knowledge, is your child currently using alcohol or drugs, or have they used them in the past?* Yes No SafetyDo you always wear a lap and shoulder seat belt and bicycle helmet?* Yes No Do you insist your child wears a lap and shoulder seat belt when in the car?* Yes No Do you insist that your child use a life jacket when they do water sports?* Yes No Does your child know how to swim?* Yes No Does your child use sunscreen?* Yes No Does your child often listen to loud music?* Yes No Is there a gun in your home or the homes where your child visits?* Yes No Is the gun unloaded and locked up?* Yes No Is the ammunition stored and locked up separately from the gun?* Yes No Have you talked with your child about gun safety?* Yes No
