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2 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
2 YEAR 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. Autism Spectrum Disorder screening is also part of this visit. Thank you.
Check o each of the tasks that your child is able to do.
Play with other children and express
interest in their play.
Takeosomeclothing.
Scoop well with a spoon.
Use 50 words.
Combine2wordsintoashortphrase
or sentence.
Followa2-stepcommand(suchas“Pickit
up and put it away”).
Nameatleast5bodyparts.
Speak so strangers can understand 50%
of what he says.
Kick a ball.
Jumpothegroundwith2feet.
Run with coordination.
Climbupaladderataplayground.
Stack objects.
Turn book pages.
Use his hands to turn objects.
Draw lines.
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
2 YEAR 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
Dyslipidemia
Does your child have parents, grandparents, or aunts or uncles who have had a stroke or
heartproblembeforeage55(male)or65(female)?
No Yes Unsure
Doesyourchildhaveaparentwith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
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
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
Intimate Partner Violence
Doyoualwaysfeelsafeinyourhome?
Yes No
Hasyourpartner,oranothersignicantpersoninyourlife,everhit,kicked,orshovedyou,orphysicallyhurt
youoryourchild?
No Yes
Living Situation and Food Security
Ispermanenthousingaworryforyou?
No Yes
Doyouhavethethingsyouneedtotakecareofyourchild?
Yes No
Doesyourhomehaveenoughheat,hotwater,electricity,andworkingappliances?
Yes No
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
Taking Care of Yourself
Doyoutaketimeforyourself?
Yes No
Doyouandyourpartnerspendtimealonetogether?
Yes No
Doyouandyourfamilydoactivitiestogether?
Yes No
Doyouhavesomeoneyoucanturntoifyouneedtotalkaboutproblems?
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
2 YEAR VISIT
YOUR CHILD’S BEHAVIOR
Isyourchildlearningnewthings?
Yes No
Doyouspendtimealonewithyourchilddoingsomethingthathelikestodo?
Yes No
Doyouencourageotherfamilymembersandcaregiverstobeconsistent,patient,andcalmwithyourchild?
Yes No
Doyoushowyourchildhowtobephysicallyactiveeverydaybyplayingandbeingactivewithher?
Yes No
Doesyourchildplaywithotherchildren?
Yes No
HowmuchtimeeverydaydoesyourchildspendwatchingTVorusingcomputers,tablets,orsmartphones?
hours
TALKING AND YOUR CHILD
Doesyourchildhavewaystotellyouwhathewants?
Yes No
Doyouusesimplewordswhenaskingyourchildaquestionortellingherwhattodo?
Yes No
Doyougiveyourchildplentyoftimetorespond?
Yes No
Doyousingsongsandtalkwithyourchildaboutthethingsyoudotogether?
Yes No
Doyoureadtoyourchildorlookatbookstogethereveryday?
Yes No
TOILET TRAINING
Isyourchildinterestedinusingthetoilet?
Yes No
Doesyourchildtellyouwhenhehasabowelmovement?
Yes No
Isyourchilddryforabout2hoursatatime?
Yes No
Doesyourchildknowthedierencebetweenbeingwetanddry?
Yes No
Doyouhelpyourchildwashherhandsaftergoingtothebathroom?
Yes No
SAFETY
Car 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
Doeseveryoneinthevehiclealwaysusealapandshoulderseatbelt,boosterseat,orcarsafetyseat?
Yes No
Outdoor Safety
Doesyourchildalwayswearabikehelmetwhensheridesonatricycle,inatowedbiketrailer,orinaseat
onanadult’sbicycle?
Yes No
Doyoukeepyourchildawayfrommovingmachines,lawnmowers,driveways,andstreets?
Yes No
Doyoulivenearanybackyardswimmingpools,hottubs,orspas?
No Yes
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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2 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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