Fillable 1 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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1 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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To provide you and your baby with the best possible health care, we would like to know how things are going. Please
answer all the questions. Maternal Depression screening is also part of this visit. Thank you.
Check o each of the tasks that your baby is able to do.
Look at you.
Follow you with her eyes.
Comfort himself by doing things such as
bringing his hands to his mouth.
Start to get fussy when she is bored.
Calm when he is picked up or spoken to.
Look briey at objects.
Make short sounds such as “ooh” and “ah.”
Become alert when she hears
unexpected sounds.
Become quiet or turn when he hears
your voice.
Show signs she is sensitive to her
surroundings (such as crying or startling) or
need extra support to handle daily activities.
Use dierent cries for hunger and tiredness.
Move both arms and legs together.
Hold his chin up when he is on his
stomach.
Open her ngers a little when at rest.
BRIGHT FUTURES PREVISIT QUESTIONNAIRE
1 MONTH VISIT
PAGE 1 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
American Academy of Pediatrics
TELL US ABOUT YOUR BABY AND FAMILY.
WHAT WOULD YOU LIKE TO TALK ABOUT TODAY?
Do you have any concerns, questions, or problems that you would like to discuss today? No Yes, describe:
YOUR GROWING AND DEVELOPING BABY
Have there been major changes lately in your baby’s or family’s life? No Yes, describe:
Have any of your baby’s relatives developed new medical problems since your last visit? No Yes Unsure If yes or unsure,
please describe:
What excites or delights you most about your baby?
Does your baby have special health care needs? No Yes, describe:
Does your baby live with anyone who smokes or spend time in places where people smoke or use e-cigarettes? No Yes Unsure
Do you have specic concerns about your baby’s development, learning, or behavior? No Yes, describe:
PATIENT NAME: DATE:
Please print.
CLEAR FORM
RISK ASSESSMENT
Tuberculosis
Was your baby 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)?
No Yes Unsure
Has your baby had close contact with a person who has tuberculosis disease or who has
had a positive tuberculosis test result?
No Yes Unsure
Is your baby infected with HIV?
No Yes Unsure
Vision
Do you have concerns about how your baby sees?
No Yes Unsure
ANTICIPATORY GUIDANCE
How are things going for you, your baby, and your family?
PAGE 2 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
1 MONTH VISIT
YOUR FAMILY’S HEALTH AND WELL-BEING
Living Situation and Food Security
Is permanent housing a worry for you?
No Yes
Do you have the things you need to take care of your baby, such as a crib, a car safety seat, and diapers?
Yes No
Does your home have enough heat, hot water, and electricity?
Yes No
Do you have health insurance for yourself?
Yes No
Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?
No Yes
Within the past 12 months, did the food you bought not last, and you did not have money to get more?
No Yes
Do you need help in nding community support services, such as WIC or food stamps?
No Yes
Have you had any problems with mold or dampness in your home?
No Yes
If your home has a basement, has it been checked for radon?
Yes No
Do you use pesticides inside or outside your home?
No Yes
Intimate Partner Violence
Do you always feel safe in your home?
Yes No
Has your partner, or another signicant person in your life, ever hit, kicked, or shoved you, or physically hurt you
or the baby?
No Yes
Maternal Alcohol and Substance Use
Does anyone in your household drink beer, wine, or liquor?
No Yes
Do you or other family members use marijuana, cocaine, pain pills, narcotics, or other controlled substances?
No Yes
Family Support
Do you feel comfortable returning to work or school after the baby’s birth?
Yes No
Have you made arrangements for child care?
Yes No
MOTHER’S HEALTH AND FAMILY RELATIONSHIPS
Have you had a post-birth checkup?
Yes No
Does your partner or do other family members help care for the baby and help around the house?
Yes No
If you have older children, are they getting along with the baby?
Yes No
CARING FOR YOUR BABY
Is your baby sleeping well?
Yes No
Does your baby use a pacier?
Yes No
Can you tell what your baby wants by how she cries?
Yes No
Are you able to calm your baby?
Yes No
Is a TV, computer, tablet, or smartphone on in the background while your baby is in the room?
No Yes
Do you put your baby on his tummy for short periods of time when he is awake and with you?
Yes No
NA
PATIENT NAME: DATE:
Please print.
NA
The information contained in this questionnaire should not be used as a substitute for the medical care and advice of your
pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and
circumstances. Original questionnaire included as part of the Bright Futures Tool and Resource Kit, 2nd Edition.
The American Academy of Pediatrics (AAP) does not review or endorse any modifications made to this questionnaire
and in no event shall the AAP be liable for any such changes.
© 2019 American Academy of Pediatrics. All rights reserved.
PAGE 3 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
1 MONTH VISIT
CARING FOR YOUR BABY (CONTINUED)
Medical Home After-hours Support
Do you know how to take your baby’s temperature rectally?
Yes No
Do you know when to call your baby’s doctor?
Yes No
General Information
Does your baby feed well?
Yes No
Do you give your baby any supplements, herbs, special teas, or vitamins?
No Yes
Can you tell when your baby is hungry?
Yes No
Can you tell when your baby is full?
Yes No
Do you ever prop the bottle rather than holding it or put your baby to bed with a bottle?
No Yes
Are you able to burp your baby?
Yes No
If you are breastfeeding, answer these questions.
Is breastfeeding uncomfortable or painful?
No Yes
Do you eat foods high in protein (such as eggs, lean meat, poultry, sh, or beans) every day?
Yes No
Are you continuing to take prenatal vitamins?
Yes No
Do you take medications (either over-the-counter or prescription) or herbal supplements?
No Yes
Are you giving your baby vitamin D drops?
Yes No
If you are formula feeding, or providing formula supplementation, answer these questions.
Are you using iron-fortied formula?
Yes No
Do you have any questions about using formula, such as how much it costs or how to prepare it?
No Yes
SAFETY
Car and Home Safety
Is your baby fastened securely in a rear-facing car safety seat in the back seat every time she rides in a vehicle?
Yes No
Are you having any problems with your car safety seat?
No Yes
Do you always keep one hand on your baby when changing diapers or clothing on a changing table, couch, or bed?
Yes No
Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?
Yes No
Safe Sleep
Does your baby sleep on his back?
Yes No
Does your baby sleep in a crib?
Yes No
Does your baby sleep in your room?
Yes No
PATIENT NAME: DATE:
Please print.
Consistent with Bright Futures: Guidelines for Health Supervision
of Infants, Children, and Adolescents, 4th Edition
For more information, go to https://brightfutures.aap.org.
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Completed 22 June 2022

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