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11 THROUGH 14 YEAR VISITS FOR PARENTS

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
11 THROUGH 14 YEAR VISITS FOR PARENTS
PAGE 1 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
American Academy of Pediatrics
To provide you and your child with the best possible health care, we would like to know how things are going.
Please answer all the questions. Thank you.
Check o all the items that you feel are true for your child.
TELL US ABOUT YOUR CHILD 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 CHILD
Have there been major changes lately in your family’s life? No Yes, describe:
Have any of your child’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 child?
Does your child have special health care needs? No Yes, describe:
My child does things that help her have a healthy lifestyle,
such as eating healthy foods, being physically active, and keeping
herself safe.
My child has at least one adult in his life who cares about him and
knows he can go to if he needs help.
My child has at least one friend or a group of friends who she feels
comfortable around.
My child helps others by himself or by working with a group in
school, a faith-based organization, or the community.
My child is able to bounce back when things don’t go her way.
Mychildfeelshopefulandself-condent.
My child is becoming more independent and making more
decisions on his own as he gets older.
PATIENT NAME: DATE:
Please print.
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes? No Yes Unsure
CLEAR FORM
RISK ASSESSMENT
ANTICIPATORY GUIDANCE
How are things going for you, your child, and your family?
11 THROUGH 14 YEAR VISITS FOR PARENTS
Anemia
Doesyourchild’sdietincludeiron-richfoods,suchasmeat,iron-fortiedcereals,orbeans?
Yes No Unsure
Hasyourchildeverbeendiagnosedwithirondeciencyanemia?
No Yes Unsure
Does your family ever struggle to put food on the table?
No Yes Unsure
If your child is female, does she have excessive menstrual bleeding or other blood loss?
No Yes Unsure
If your child is female, does her period last more than 5 days?
No Yes Unsure
Dyslipidemia
Does your child have parents, grandparents, or aunts or uncles who have had a stroke or
heart problem before age 55 (males) or 65 (females)?
No Yes Unsure
Does your child have a parent with an elevated blood cholesterol level (240 mg/dL or higher)
or who is taking cholesterol medication?
No Yes Unsure
Hearing
Do you have concerns about how your child hears?
No Yes Unsure
Oral health
Doesyourchild’sprimarywatersourcecontainuoride?
Yes No Unsure
Sexually
transmitted
infections/
HIV
Adolescents 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?
No Yes Unsure
Tuberculosis
Is your child infected with HIV?
No Yes Unsure
Was 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)?
No Yes Unsure
Has your child had close contact with a person who has tuberculosis disease or who has had
a positive tuberculosis test result?
No Yes Unsure
Vision
Do you have concerns about how your child sees?
No Yes Unsure
Does your child have trouble with near or far vision?
No Yes Unsure
Has your child ever failed a school vision screening test?
No Yes Unsure
Does your child tend to squint?
No Yes Unsure
YOUR FAMILY’S HEALTH AND WELL-BEING
Interpersonal Violence (Fighting and Bullying)
Are there frequent reports of violence in your community or school?
No Sometimes Yes
Is your child involved in any of the violence?
No Sometimes Yes
Do you think your child is safe in the neighborhood?
Yes Sometimes No
Hasyourchildeverbeeninjuredinaght?
No Sometimes Yes
Has your child been bullied or hurt by others?
No Sometimes Yes
Has your child bullied or been aggressive toward others?
No Sometimes Yes
Have you talked with your child about violence in dating situations and how to be safe?
Yes Sometimes No
Living Situation and Food Security
Do you have concerns about your living situation?
No Sometimes Yes
Do you have enough heat, hot water, and electricity?
Yes Sometimes No
Do you have appliances that work?
Yes Sometimes No
Do you have problems with bugs, rodents, or peeling paint or plaster?
No Sometimes Yes
In the past 12 months, did you worry that your food would run out before you got money to buy more?
No Sometimes Yes
In the past 12 months, did the food you bought not last, and you did not have money to buy more?
No Sometimes Yes
PAGE 2 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
PATIENT NAME: DATE:
Please print.
PAGE 3 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
11 THROUGH 14 YEAR VISITS FOR PARENTS
YOUR FAMILY’S HEALTH AND WELL-BEING (CONTINUED)
Alcohol and Drugs
Is there anyone in your child’s life whose alcohol or drug use concerns you?
No Sometimes Yes
Connectedness With Family and Peers
Does your family get along well with each other?
Yes Sometimes No
Do you take time to talk with your child every day?
Yes Sometimes No
Does your family do things together?
Yes Sometimes No
Does your child have chores or responsibilities at home?
Yes Sometimes No
Do you have clear rules and expectations for your child?
Yes Sometimes No
Do you let your child know when he does something good?
Yes Sometimes No
Connectedness With Community
Does your child have interests outside of school?
Yes Sometimes No
Does your child help others at home, in school, or in your community?
Yes Sometimes No
School Performance
Is your child getting to school on time?
Yes Sometimes No
Is your child having any problems at school?
No Sometimes Yes
Does your child complete homework on time?
Yes Sometimes No
Has your child missed more than 2 days of school in any month?
No Sometimes Yes
Coping With Stress and Decision-making
Does your child worry too much or appear overly anxious?
No Sometimes Yes
Have you discussed ways to deal with stress?
Yes Sometimes No
Do you help your child make decisions and solve problems?
Yes Sometimes No
YOUR GROWING AND CHANGING CHILD
Healthy Teeth
Does your child see the dentist regularly?
Yes Sometimes No
Do you have trouble getting dental care?
No Sometimes Yes
Body Image
Do you have any concerns about your child’s nutrition, weight, or physical activity?
No Sometimes Yes
Does your child talk about getting fat or dieting to lose weight?
No Sometimes Yes
Healthy Eating
Do you think your child eats healthy foods?
Yes Sometimes No
Doyouhaveanydicultygettinghealthyfoodforyourfamily?
No Sometimes Yes
Do you have any concerns about your child’s eating habits or nutrition?
No Sometimes Yes
Do you eat meals together as a family?
Yes Sometimes No
Physical Activity and Sleep
Is your child physically active at least 1 hour a day? This includes running, playing sports, or doing
physically active things with friends.
Yes Sometimes No
Are there opportunities to safely play outside in your neighborhood?
Yes Sometimes No
Do you and your child participate in physical activities together?
Yes Sometimes No
How much time does your child spend on recreational screen time each day?
hours
Does your child have a TV, computer, tablet, or smartphone in his bedroom?
No Sometimes Yes
Do you have rules about screen time for your child?
Yes Sometimes No
Has your family made a family media use plan to help everyone balance time spent on media with other
family and personal activities?
Yes Sometimes No
Does your child have a regular bedtime?
Yes Sometimes No
PATIENT NAME: DATE:
Please print.
11 THROUGH 14 YEAR VISITS FOR PARENTS
YOUR CHILD’S EMOTIONAL WELL-BEING
Mood and Mental Health
Is your child frequently irritable?
No Sometimes Yes
Have you noticed any changes in your child’s weight or sleep habits?
No Sometimes Yes
Doyouandyourchildoftenhaveconictsaboutwhatyourcultureexpectsforherbehaviorandhowher
friends behave?
No Sometimes Yes
Do you have any concerns about your child’s emotional health, such as being frequently sad or
depressed?
No Sometimes Yes
Sexuality
Have you and your child talked about how his body will change during puberty?
Yes Sometimes No
Do you have house rules about curfews, dating, and friends?
Yes Sometimes No
HEALTHY BEHAVIOR CHOICES
Sexual Activity
Have you and your child talked about sex?
Yes Sometimes No
Have you talked about ways to deal with any pressures to have sex?
Yes Sometimes No
Substance Use
Have you talked with your child about alcohol and drug use?
Yes Sometimes No
Do you know your child’s friends?
Yes Sometimes No
Do you know where your child is and what she does after school and on the weekends?
Yes Sometimes No
Do you have consequences for your child if you discover he is using tobacco, alcohol, or drugs?
Yes Sometimes No
To your knowledge, is your child currently using alcohol or drugs, or has she used them in the past?
No Sometimes Yes
Acoustic Trauma
Does your child often listen to loud music?
No Sometimes Yes
SAFETY
Seat Belt and Helmet Use
Do you always wear a lap and shoulder seat belt and bicycle helmet?
Yes Sometimes No
Do you insist your child wears a lap and shoulder seat belt when in a car?
Yes Sometimes No
Do you insist that your child use a life jacket when he does water sports?
Yes Sometimes No
Sun Protection
Does your child use sunscreen?
Yes Sometimes No
Gun Safety
Is there a gun in your home or the homes where your child visits?
No Sometimes Yes
If yes, is the gun unloaded and locked up?
Yes Sometimes No
If yes, is the ammunition stored and locked up separately from the gun?
Yes Sometimes No
Have you talked with your child about gun safety?
Yes Sometimes No
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 4 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
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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