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18 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
18 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. Child Development and Autism Spectrum Disorder screenings are also part of this
visit. Thank you.
Check o each of the tasks that your child is able to do.
Engage with others for play.
Help dress and undress himself.
Point to pictures in a book.
Point to an interesting object to draw
your attention to it.
Turn and look at an adult if something
new happens.
Begin to scoop with a spoon.
Use words to ask for help.
Identify at least 2 body parts.
Name at least 5 familiar objects,
such as ball or milk.
Walk up with 2 feet per step with his
hand held.
Sit in a small chair.
Carry a toy while walking.
Scribble spontaneously.
Throw a small ball a few feet
while standing.
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:
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes? No Yes Unsure
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
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
18 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
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 was renovated in the past 6 months?
No Yes Unsure
Oral health
Does your child have a dentist?
Yes No Unsure
Does your child’s primary water source contain uoride?
Yes No 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 CHILD’S BEHAVIOR
Do you praise your child for good behavior?
Yes No
If your child is upset, do you help distract him with another activity, book, or toy?
Yes No
Do other caregivers set the same limits for your child as you do?
Yes No
Do you use time-outs as a way to manage your child’s behavior?
Yes No
Have you thought about toilet training?
Yes No
If you are planning to have another baby, have you thought about how you will prepare your child?
Yes No
TALKING AND COMMUNICATING
Do you read, sing, and talk with your child about what you are seeing and doing?
Yes No
Does he wave “bye-bye”?
Yes No
Do you use s
imple words to tell your child what to do?
Yes No
YOUR CHILD AND TV
How much time every day does your child spend watching TV or using computers, tablets, or smartphones? hours
If your child uses media, do you monitor the shows your child watches or activity she does?
Yes No
HEALTHY EATING
Do you provide a variety of vegetables, fruits, and other nutritious foods?
Yes No
Does your child eat much food that you would describe as junk food?
No Yes
Does your child drink water every day?
Yes No
Is your child willing to try new foods?
Yes No
SAFETY
Car and Home Safety
Is your child fastened securely in a rear-facing car safety seat in the back seat car every time he rides in a vehicle?
Yes No
Does everyone in the car always use a lap and shoulder seat belt, booster seat, or car safety seat?
Yes No
Do you have emergency phone numbers near every telephone and in your cell phone for rapid dial?
Yes No
Do you keep cigarettes, lighters, matches, and alcohol out of your child’s sight and reach?
Yes No
NA
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
18 MONTH VISIT
SAFETY (CONTINUED)
Car and Home Safety (continued)
Do you keep your child away from the stove, replaces, and space heaters?
Yes No
Do you have a gate at the top and bottom of all stairs in your home?
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
Are your TVs, bookcases, and dressers secured to the wall so they cannot fall over and hurt your child?
Yes No
Do you have any questions about other ways to keep your home safe?
No Yes
Sun Protection
Do you apply sunscreen on your child whenever she plays outside?
Yes No
Gun Safety
Does anyone in your home or the homes where your child spends time have a gun?
No Yes
If yes, is the gun unloaded and locked up?
Yes No
If yes, is the ammunition stored and locked up separately from the gun?
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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