Bright Futures Physical Exam Pre-visit (9-10 years 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 that are true for your child.* Shows the ability to get along with others and control his emotions Chooses to eat healthy foods and participate in physical activity every day Forms caring, supportive relationships with family members, other adults, and peers Risk Assessment AnemiaDoes your child’s diet include iron rich foods, such as meat, iron-fortified cereals, or beans?* Yes No Unsure Does your child eat a vegetarian diet (does not eat red meat, chicken, fish or seafood)?* Yes No Unsure If your child is a vegetarian (does not eat red meat, chicken, fish, or seafood), does your child take an iron supplement?* 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 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 Has your child ever failed a school vision screening test?* Yes No Unsure Does you child tend to squint?* Yes No Unsure Neighborhood and Family Violence (Bullying and Fighting)Are there frequent reports of violence in your community or school?* Yes No Has your child ever been bullied or hurt physically by someone?* Yes No Has your child felt excluded or not a part of any group of friends?* Yes No Has your child ever told you they were touched in a way that made them uncomfortable or on their private parts?* Yes No Living Situation and Food SecurityWithin 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 Do any of your child’s friends smoke, use or vape e-cigarettes, drink alcohol or beer, or use drugs?* Yes No Harm from the InternetDo you supervise your child’s internet use?* Yes No Do you have rules about internet use?* Yes No Have you installed an internet safety filter on your computers, tablets, and smartphones?* Yes No Emotional Security and Self-EsteemDoes your child usually seem happy?* Yes No Are there things your child is really good at doing or is proud of?* Yes No Does your child have a chance to help others at home, at school, or in your community?* Yes No Connectedness with Family and PeersDo your family members get along well with each other?* Yes No Does your family do things together?* Yes No Does your child have chores and responsibilities at home?* Yes No Does your child have friends at school or in your neighborhood?* Yes No Your Child’s DevelopmentHas your child experienced any recent stresses at home or in school?* Yes No Do you have clear rules and expectations for your child?* Yes No When your child breaks the rules, are you consistent with consequences and discipline?* Yes No Do you help your child control their anger, deal with worries, and solve problems?* Yes No Have you and your child talked about how to say no to smoking, alcohol, and drug use?* Yes No Have you talked with your child about the body changes that occur during puberty?* Yes No Have you discussed privacy and body safety with your child?* Yes No Have you and your child talked about sex?* Yes No Does your child know to tell a trusted adult if someone touches their private parts or is someone encourages them to do other things that make them uncomfortable or they know are wrong?* Yes No SchoolDo you have concerns about your child’s school experience?* Yes No Has your child missed more than 2 days of school in any month?* Yes No Does your child have any difficulties at school or get extra help?* Yes No Does your child participate in activities outside of school?* Yes No Healthy TeethDoes your child brush and floss their teeth every day?* Yes No Does your child see the dentist twice a year?* Yes No Does your child use a mouth guard when playing contact sports?* Yes No Does your child regularly drink soda, juice, or other sugar-sweetened drinks?* Yes No NutritionDo you have any concerns about your child’s weight?* Yes No Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.?* Yes No Do you eat family meals together?* Yes No Do you hear your child talk about how they look or dieting?* Yes No Physical ActivityIs your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.* Yes No Do you have any concerns about your child’s physical activity level, such as it being either too much or too little?* Yes No Does your child have trouble going to sleep or do they wake up during the night?* 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 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 SafetyDoes your child always sit in a belt-positioning booster seat or lap and shoulder seat belt in the back seat every time they ride in a vehicle?* Yes No Does everyone in the vehicle always use a lap and shoulder seat belt?* Yes No Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?* Yes No Does your child know how to swim?* Yes No Does your child know to always have an adult watching them in the water and never to swim alone?* Yes No Does your child always use sunscreen when playing outside?* Yes No Do you know your child’s friends and their families?* Yes No Does your child know how to get help in an emergency if you aren’t there?* Yes No Does anyone in your home or the homes where your child spends time have a gun?* 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 to your child about gun safety?* Yes No
