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3 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
3 YEAR VISIT
PAGE 1 of 4
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.
Go to the bathroom and urinate by herself.
Put on a coat, jacket, or shirt by himself.
Eat by herself.
Begin to play make-believe.
Play and share with others.
Use 3-word sentences.
Speak so strangers can understand 75% of
what he says.
Tell you a story from a book or TV.
Compare things using words such as bigger
and shorter.
Understand simple prepositions, such as on
or under.
Pedal a tricycle.
Climbonandoacouchorchair.
Jump forward.
Draw a single circle.
Draw a person with head and one other
body part.
Cut with child scissors.
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
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CLEAR FORM
RISK ASSESSMENT
ANTICIPATORY GUIDANCE
How are things going for you, your child, and your family?
PAGE 2 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
3 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
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
YOUR FAMILY’S HEALTH AND WELL-BEING
Living Situation and Food Security
Do you have enough heat, hot water, electricity, and working appliances?
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
Positive Family Interactions
Areyourfamilymemberslovingandaectionatewithoneanother?
Yes No
Do you praise your child when he is being good?
Yes No
Do you have ways to constructively handle anger and settle disputes in your family?
Yes No
Does everyone who cares for your child set the same limits for your child?
Yes No
Do you allow your child to make choices, such as what clothes to wear or what books to read?
Yes No
Do you use simple words when asking your child a question or telling her what to do?
Yes No
Taking Care of Yourself
Do you take time for yourself?
Yes No
Do you feel you are able to balance family and work?
Yes No
Do you spend time alone with your partner?
Yes No
PLAYING WITH SIBLINGS AND PEERS
Does your child engage in fantasy play with dolls, toy animals, or blocks?
Yes No
Do you spend time alone with your child doing things you both enjoy?
Yes No
Does your child have chances to play with other children (such as on playdates and at preschool)?
Yes No
PATIENT NAME: DATE:
Please print.
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PAGE 3 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
3 YEAR VISIT
PLAYING WITH SIBLINGS AND PEERS (CONTINUED)
When your child plays with other children, do you help him learn how to take turns?
Yes No
If you have other children, do they get along with each other?
Yes No
Are you expecting or thinking about having another child?
No Yes
READING AND TALKING WITH YOUR CHILD
Do you read, sing songs, or play word games with your child every day?
Yes No
When you are reading together, do you ask your child questions about the pictures or story in the book?
Yes No
Do you encourage your child to tell you about his day?
Yes No
Does your family speak more than one language at home?
No Yes
EATING HEALTHY AND BEING ACTIVE
Nutritious Foods
Does your child drink water every day?
Yes No
How many ounces of milk does your child drink on most days?
oz
Doyouoeryourchildavarietyoffoods,includingvegetables,fruits,andfoodsrichinprotein,suchasmeat,eggs,
chicken,orsh?
Yes No
Isyourchildwillingtotrynewavorsandfoodtextures?
Yes No
Do you let your child decide how much to eat and when to stop?
Yes No
Promoting Physical Activity and Limiting TV
Are you physically active together as a family, such as going on walks or playing in the park?
Yes No
Does your child play actively for at least 1 hour a day?
Yes No
How much time every day does your child spend watching TV or using computers, tablets, or smartphones?
hours
Does your child have a TV or an Internet-connected device in her bedroom?
No Yes
Has your family made a media use plan to help everyone balance time spent on media with other family and personal
activities?
Yes No
SAFETY
Car and Home Safety
Is your child buckled securely in a car safety seat in the back seat every time he rides in a vehicle?
Yes No
Are you having any problems with your car seat?
No Yes
Does everyone in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
Yes No
Do you cut foods such as grapes and hot dogs into small pieces to prevent choking?
Yes No
Does your child play in a driveway or close to the street?
No Yes
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
Water Safety
Are there swimming pools near your home?
No Yes
Do you always stay within arm’s reach of your child when he is in or near water?
Yes No
Does your child always wear an US Coast Guard–approved life jacket when on a boat?
Yes No
Pets
Do you own a pet?
No Yes
Have you taught your child how to behave around animals so she does not get bitten or scratched?
Yes No
NA
PATIENT NAME: DATE:
Please print.
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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
3 YEAR VISIT
PATIENT NAME: DATE:
Please print.
SAFETY (CONTINUED)
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
Consistent with Bright Futures: Guidelines for Health Supervision
of Infants, Children, and Adolescents, 4th Edition
For more information, go to https://brightfutures.aap.org.
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3 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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