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12 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
12 MONTH VISIT
PAGE 1 of 3
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 each of the tasks that your child is able to do.
Look for hidden objects.
Imitate new gestures.
Say, “Dad” or “Mom” with meaning
Use one word other than Mom, Dad, or
personal names.
Follow a verbal command that includes a
gesture.
Takerstindependentsteps.
Stand without support.
Drop objects in a cup.
Pickupsmallobjectwith2-nger
pincer grasp.
Pick up food and eat it.
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 child’s or 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:
Doyouhavespecicconcernsaboutyourchild’sdevelopment,learning,orbehavior? No Yes, describe:
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
Downloaded from https://toolkits.solutions.aap.org on 05/28/2019 Terms of use: http://solutions.aap.org/ss/terms.aspx
CLEAR FORM
RISK ASSESSMENT
ANTICIPATORY GUIDANCE
How are things going for you, your child, and your family?
PAGE 2 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
12 MONTH VISIT
Hearing
Do you have concerns about how your child hears?
No Yes Unsure
Do you have concerns about how your child speaks?
No Yes Unsure
Lead
Doesyourchildliveinorvisitahomeorchildcarefacilitywithanidentiedleadhazardora
home built before 1960 that is in poor repair or that was renovated in the past 6 months?
No Yes Unsure
Oral health
Doesyourchild’sprimarywatersourcecontainuoride?
Yes No Unsure
Tuberculosis
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
Is your child infected with HIV?
No Yes Unsure
Vision
Do you have concerns about how your child sees?
No Yes Unsure
Do your child’s eyes appear unusual or seem to cross?
No Yes Unsure
Do your child’s eyelids droop or does one eyelid tend to close?
No Yes Unsure
Have your child’s eyes ever been injured?
No Yes Unsure
YOUR FAMILY’S HEALTH AND WELL-BEING
Living Situation and Food Security
Do you have enough heat, hot water, electricity, and working appliances in your home?
Yes No
Do you have problems with bugs, rodents, peeling paint or plaster, mold, or dampness?
No Yes
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
Alcohol and Drugs
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
Social Connections With Family, Friends, Child Care, Home Visitation Program Sta, and Others
Do you have child care or an adult you trust to care for your child?
Yes No
Have you talked about your thoughts on feeding, sleeping, discipline, and media use with your caregiver?
Yes No
Do you participate in activities outside your home? These may be social, religious, volunteer, or recreational programs.
Yes No
CARING FOR YOUR CHILD
If your child is upset, do you help distract him using another activity, book, or toy?
Yes No
Do you use time-outs as a way to manage your child’s behavior?
Yes No
Do you have any questions about what to do when you become angry or frustrated with your child?
No Yes
Does your family regularly make time for reading, playing, and talking together?
Yes No
Do you eat together as a family?
Yes No
Do you have regular mealtimes and snack times?
Yes No
Do you help your child feel comfortable around new people and new situations?
Yes No
Do you have regular nap time and bedtime routines for your child, such as reading books and brushing teeth?
Yes No
PATIENT NAME: DATE:
Please print.
Downloaded from https://toolkits.solutions.aap.org on 05/28/2019 Terms of use: http://solutions.aap.org/ss/terms.aspx
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
12 MONTH VISIT
CARING FOR YOUR CHILD (CONTINUED)
Does your child watch TV or play on a tablet or smartphone?
If yes, how much time each day? ____ hours
No Yes
Have you made a family media use plan to help you balance media use with other family activities?
Yes No
FEEDING YOUR CHILD
Does your child try feeding herself using a spoon?
Yes No
Does your child drink from a cup?
Yes No
Do you give your child small, hard foods such as peanuts and popcorn?
No Yes
Do you give your child round foods such as hot dogs, raw carrots, grapes, and grape tomatoes?
No Yes
Do you include your child in family meals?
Yes No
Have you begun to serve your child cow’s milk?
Yes No
Does your child eat vegetables and fruits?
Yes No
Doesyourchildeatfoodsrichinprotein,suchaseggs,leanmeat,chicken,orsh?
Yes No
Do you let your child decide what and how much to eat?
Yes No
HEALTHY TEETH
Doyoubrushyourchild’steethwithasmearofuoridatedtoothpaste2timesadayusingasofttoothbrush?
Yes No
SAFETY
Car and Home Safety
Is your child fastened securely in a rear-facing car safety seat in the back seat every time he rides in a vehicle?
Yes No
Are you having any problems using your car safety seat?
No Yes
Do you have a gate at the top and bottom of all stairs in your home?
Yes No
Is the mattress in your child’s crib set on the lowest setting to prevent falls?
Yes No
Do you keep household cleaners, chemicals, and medicines locked up and out of your child’s sight and reach?
Yes No
Do all your electrical outlets have covers?
Yes No
Do you keep sharp objects, plastic bags, and electrical or drapery cords out of your child’s reach?
Yes No
Doyoukeepyourchildawayfromthestove,replaces,andspaceheaters?
Yes No
Are your TVs, bookcases, and dressers secured to the wall so they cannot fall over and hurt your child?
Yes No
Water and Sun Safety
Do you always stay within arm’s reach of your child when he is in the bath?
Yes No
Do you have a swimming pool, pond, or lake in or near your home?
No Yes
Do you put a hat on your child and apply sunscreen on her when you go outside?
Yes No
Pets
Do you own a pet?
No Yes
If so, does your child interact with the pet?
No Yes
PATIENT NAME: DATE:
Please print.
NA
Consistent with Bright Futures: Guidelines for Health Supervision
of Infants, Children, and Adolescents, 4th Edition
For more information, go to https://brightfutures.aap.org.
Downloaded from https://toolkits.solutions.aap.org on 05/28/2019 Terms of use: http://solutions.aap.org/ss/terms.aspx
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12 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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