Fillable 15 THROUGH 17 YEAR VISITS FOR PARENTS

Fill Online, Printable, Fillable, Blank 15 THROUGH 17 YEAR VISITS FOR PARENTS Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

15 THROUGH 17 YEAR VISITS FOR PARENTS

On average this form takes 64 minutes to complete

The 15 THROUGH 17 YEAR VISITS FOR PARENTS form is 4 pages long and contains:

  • 0 signatures
  • 7 check-boxes
  • 252 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BRIGHT FUTURES PREVISIT QUESTIONNAIRE
15 THROUGH 17 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 teen 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 teen.
TELL US ABOUT YOUR TEEN.
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 TEEN
Have there been major changes lately in your teen’s or family’s life? No Yes, describe:
Have any of your teen’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 teen?
Does your teen have special health care needs? No Yes, describe:
My teen does things that help her have a healthy lifestyle,
such as eating healthy foods, being physically active, and keeping
herself safe.
My teen has at least one adult in his life who cares about him and
knows he can go to if he needs help.
My teen has at least one friend or a group of friends who she feels
comfortable around.
My teen helps others by himself or by working with a group in
school, a faith-based organization, or the community.
My teen is able to bounce back when things don’t go her way.
Myteenfeelshopefulandself-condent.
My teen is becoming more independent and making more
decisions on his own as he gets older.
PATIENT NAME: DATE:
Please print.
Does your teen 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 teen, and your family?
15 THROUGH 17 YEAR VISITS FOR PARENTS
Anemia
Doesyourteen’sdietincludeiron-richfoods,suchasmeat,iron-fortiedcereals,orbeans?
Yes No Unsure
Hasyourteen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 teen is female, does she have excessive menstrual bleeding or other blood loss?
No Yes Unsure
If your teen is female, does her period last more than 5 days?
No Yes Unsure
Dyslipidemia
Does your teen 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 teen 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 teen hears?
No Yes Unsure
Oral health
Doesyourteen’sprimarywatersourcecontainuoride?
Yes No Unsure
Sexually
transmitted
infections/
HIV
Teens who are sexually active are at risk of acquiring sexually transmitted infections,
including HIV. Teens who use injection drugs are at risk of acquiring HIV. Are you concerned
that your teen might be at risk?
No Yes Unsure
Tuberculosis
Is your teen infected with HIV?
No Yes Unsure
Was your teen 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 teen 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 teen sees?
No Yes Unsure
Does your teen have trouble with near or far vision?
No Yes Unsure
Has your teen ever failed a school vision screening test?
No Yes Unsure
Does your teen 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 teen involved in that violence?
No Sometimes Yes
Hasyourteeneverbeenthreatenedwithphysicalharmorbeeninjuredinaght?
No Sometimes Yes
Has your teen bullied others?
No Sometimes Yes
Hasyourteenbeensuspendedfromschoolbecauseofghting,bullying,orcarryingaweapon?
No Sometimes Yes
Do you know your teen’s friends and the activities they participate in or attend?
Yes Sometimes No
If your teen is in a relationship, is it respectful?
Yes Sometimes No
Would your teen tell you if someone pressured or forced her to have sex?
Yes Sometimes No
Living Situation and Food Security
Do you have concerns about your living situation?
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
Alcohol and Drugs
Is there anyone in your teen’s life whose alcohol or drug use concerns you?
No Sometimes Yes
PAGE 2 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
PATIENT NAME: DATE:
Please print.
NA
PAGE 3 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
15 THROUGH 17 YEAR VISITS FOR PARENTS
YOUR FAMILY’S HEALTH AND WELL-BEING (CONTINUED)
Connectedness With Family and Peers
Does your family get along well with each other?
Yes Sometimes No
Does your family do things together?
Yes Sometimes No
Does your teen have chores or responsibilities at home?
Yes Sometimes No
Do you set clear rules and expectations for your teen?
Yes Sometimes No
Connectedness With Community
Does your teen have interests outside of school?
Yes Sometimes No
Are there things your teen does that you are proud of?
Yes Sometimes No
School Performance
Does your teen get to school on time?
Yes Sometimes No
Does your teen attend school almost every day?
Yes Sometimes No
Doyourecognizeyourteen’ssuccessesandsupporthiseorts?
Yes Sometimes No
Does your teen have plans for after high school?
Yes Sometimes No
Coping With Stress and Decision-making
Have you talked with your teen about ways to deal with stress?
Yes Sometimes No
Do you help your teen make decisions and solve problems?
Yes Sometimes No
YOUR GROWING AND CHANGING TEEN
Healthy Teeth
Does your teen 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 teen’s weight, eating habits, or physical activity?
No Sometimes Yes
Does your teen talk about getting fat or dieting to lose weight?
No Sometimes Yes
Healthy Eating
Do you think your teen eats healthy foods?
Yes Sometimes No
Doyouhaveanydicultygettinghealthyfoodforyourfamily?
No Sometimes Yes
Do you eat meals together as a family?
Yes Sometimes No
Physical Activity and Sleep
Is your teen 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 exercise outside in your neighborhood?
Yes Sometimes No
Do you and your teen participate in physical activities together?
Yes Sometimes No
How much time does your teen spend on recreational screen time each day?
hours
Does your teen have a TV, computer, tablet, or smartphone in his bedroom?
No Sometimes Yes
Has your family made a media use plan to help everyone balance time spent on media with other family
and personal activities?
Yes Sometimes No
Does your teen have a regular bedtime?
Yes Sometimes No
Do you think your teen gets enough sleep?
Yes Sometimes No
YOUR TEEN’S EMOTIONAL WELL-BEING
Mood and Mental Health
Have you noticed any changes in your teen’s weight, sleep habits, or behaviors?
No Sometimes Yes
Is your teen frequently irritable?
No Sometimes Yes
Do you have concerns about your teen’s emotional health, such as being frequently sad or depressed?
No Sometimes Yes
Do you think your teen worries too much or appears overly anxious?
No Sometimes Yes
PATIENT NAME: DATE:
Please print.
15 THROUGH 17 YEAR VISITS FOR PARENTS
YOUR TEEN’S EMOTIONAL WELL-BEING (CONTINUED)
Sexuality
Have you talked with your teen about relationships, dating, and sex?
Yes Sometimes No
Have you talked with your teen about his sexuality?
Yes Sometimes No
Do you have house rules about curfews, parties, dating, and friends?
Yes Sometimes No
Do you know where your teen’s friends are and what they’re doing?
Yes Sometimes No
HEALTHY BEHAVIOR CHOICES
Sexual Activity
Are you worried about sexual pressures on your teen?
No Sometimes Yes
Substance Use
Have you talked with your teen about alcohol and drug use?
Yes Sometimes No
To your knowledge, is your teen currently using alcohol or drugs, or has she used them in the past?
No Sometimes Yes
Have you discussed consequences if you discover your teen is using tobacco, alcohol, or drugs?
Yes Sometimes No
Acoustic Trauma
Does your teen often listen to loud music?
No Sometimes Yes
SAFETY
Seat Belt and Helmet Use
Does your teen always wear a lap and shoulder seat belt and bicycle helmet?
Yes Sometimes No
Do you have rules or restrictions around driving?
Yes Sometimes No
Sun Protection
Does your teen use sunscreen?
Yes Sometimes No
Gun Safety
Is there a gun in your home or the homes where your teen spends time?
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 teen 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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

15 THROUGH 17 YEAR VISITS FOR PARENTS

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document