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15 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
15 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.
Imitate scribbling.
Drink from cup with little spilling.
Point to ask for something or to get help.
Look around when you say things such as
“Where’s your ball?” and “Where’s your
blanket?”
Use 3 words other than names.
Speak in sounds that seem like an
unknown language.
Follow directions that do not include a
gesture.
Squat to pick up objects.
Crawl up a few steps.
Run.
Make marks with a crayon.
Drop an object into and take the object
out of a container.
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
15 MONTH VISIT
Anemia
Does your child’s diet include iron-rich foods, such as meat, iron-fortied cereals, or beans?
Yes No Unsure
Do you ever struggle to put food on the table?
No Yes Unsure
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
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
TALKING AND FEELING
Is your child learning new things?
Yes No
Does your child show any worries or fears when meeting new people?
No Yes
Do you take time for yourself?
Yes No
Do you spend time alone with your partner?
Yes No
Does your child point to something he wants and then watch to see if you see what he’s doing?
Yes No
Does she wave “bye-bye”?
Yes No
Do you talk to, sing to, and look at books with your child every day?
Yes No
SLEEP ROUTINES AND ISSUES
Does your child have a regular bedtime routine?
Yes No
Does your child sleep well?
Yes No
How many hours does your child sleep?
_____ Daytime _____ Nighttime
Does your child have a blanket, stued animal, or toy that he likes to sleep with?
Yes No
Do you have a TV or an Internet-connected device in your child’s bedroom?
No Yes
TANTRUMS AND DISCIPLINE
Does your child have frequent tantrums?
No Yes
If your child is upset, do you help distract her with another activity, book, or toy?
Yes No
Do you set limits for your child?
Yes No
Do other caregivers set the same limits for your child as you do?
Yes No
Do you praise your child when he is being good?
Yes No
Do you have any questions about what to do when you become angry or frustrated with your child?
No Yes
HEALTHY TEETH
Has your child been to a dentist?
Yes No
Do you brush your child’s teeth with a smear of uoridated toothpaste 2 times a day using a soft toothbrush?
Yes No
Does your child use a bottle?
No Yes
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
15 MONTH VISIT
SAFETY
Car and Home Safety
Is your child fastened securely in a rear-facing car safety seat in the back seat every time she rides in a vehicle?
Yes No
Does everyone in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
Yes No
Do you keep cleaners and medicines locked up and out of your child’s sight and reach?
Yes No
Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?
Yes No
Do you keep furniture away from windows and use operable window guards on windows on the second oor and higher?
(Operable means that, in case of an emergency, an adult can open the window.)
Yes No
Do you have a gate at the top and bottom of all stairs in your home?
Yes No
Do you keep cigarettes, lighters, matches, and alcohol out of your child’s sight and reach?
Yes No
Do you keep your child away from the stove?
Yes No
Do you have working smoke alarms on every oor of your home?
Yes No
Do you test the batteries once a month?
Yes No
Do you have a re escape plan?
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.
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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Completed 22 June 2022

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