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4 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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To provide you and your baby with the best possible health care, we would like to know how things are going. Please
answer all the questions. Maternal Depression screening is also part of this visit. Thank you.
Check o each of the tasks that your baby is able to do.
Laugh out loud.
Look for you or another caregiver
when he is upset.
Turn toward voices.
Make extended cooing sounds.
Support herself on her elbows and wrists
when she is on her tummy.
Roll over from his tummy to his back.
Keepherhandsopen,notinast.
Playwithhisngers.
Grasp objects.
BRIGHT FUTURES PREVISIT QUESTIONNAIRE
4 MONTH VISIT
PAGE 1 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
American Academy of Pediatrics
TELL US ABOUT YOUR BABY 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 BABY
Have there been major changes lately in your baby’s or family’s life? No Yes, describe:
Have any of your baby’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 baby?
Does your baby have special health care needs? No Yes, describe:
Does your baby live with anyone who smokes or spend time in places where people smoke or use e-cigarettes? No Yes Unsure
Doyouhavespecicconcernsaboutyourbaby’sdevelopment,learning,orbehavior? No Yes, describe:
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
ANTICIPATORY GUIDANCE
How are things going for you, your baby, and your family?
PAGE 2 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
4 MONTH VISIT
YOUR FAMILY’S HEALTH AND WELL-BEING
Living Situation
Are you or is anyone else in your household exposed to harmful substances, such as lead? This may occur in a work
environment such as construction, farming, or factory work.
No Yes
Family Relationships and Support
Do you have someone to turn to when problems arise?
Yes No
Haveyouandyourpartnerbeenabletondtimealone?
Yes No
If you have other children, are you able to spend time with each of them alone?
Yes No
Have you returned to work or school or do you plan to do so?
No Yes
Ifso,haveyoubeenabletondsomeonetocareforyourbaby?
Yes No
Do you get a daily report on your baby’s activities from your caregiver? It may include feeding, elimination, sleep,
and playtime.
Yes No
CARING FOR YOUR BABY
Your Changing Baby
Are you able to calm your baby when he is crying?
Yes No
Are you ever afraid that you or other caregivers may hurt the baby?
No Yes
Are you beginning to understand your baby’s likes and dislikes?
Yes No
Do you have a daily routine for feedings, naps, and bedtime?
Yes No
Is a TV, computer, tablet, or smartphone on in the background when your baby is in the room?
No Yes
Does your baby watch TV or play on a tablet or smartphone?
If yes, how much time each day? _____ hours
No Yes
Do you put your baby on her tummy for short periods of time when she is awake and with you?
Yes No
Do you and your baby enjoy quiet activities, such as reading, singing, or taking walks outside?
Yes No
HEALTHY TEETH
Taking Care of Your Teeth
Doyouregularlyseeadentistandbrushandossyourteeth?
Yes No
Taking Care of Your Baby’s Teeth
Is your baby showing signs of teething, such as drooling?
No Yes
Do you let your baby have a bottle in the crib?
No Yes
Do you have any questions about how to clean your baby’s gums or teeth?
No Yes
FEEDING YOUR BABY
General Information
Are you feeding your baby anything other than breast milk or formula?
No Yes
Are you comfortable waiting until your baby is about 6 months old to begin introducing solid foods?
Yes No
Can you tell when your baby is hungry?
Yes No
Can you tell when your baby is full?
Yes No
NA
RISK ASSESSMENT
Anemia
Isyourbabydrinkinganythingotherthanbreastmilkoriron-fortiedformula?
No Yes Unsure
Hearing
Do you have concerns about how your baby hears?
No Yes Unsure
Vision
Do you have concerns about how your baby sees?
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
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
4 MONTH VISIT
FEEDING YOUR BABY (CONTINUED)
If you are breastfeeding, answer these questions.
Are you still giving your baby vitamin D drops?
Yes No
Do you take any supplements, herbs, vitamins, or medications?
No Yes
Do you have questions about pumping and storing your breast milk?
No Yes
If you are formula feeding, or providing formula supplementation, answer these questions.
Areyouusingiron-fortiedformula?
Yes No
Do you have questions about using formula, such as how much it costs or how to prepare it?
No Yes
SAFETY
Car and Home Safety
Is your baby fastened securely in a rear-facing car safety seat in the back seat every time she rides in a vehicle?
Yes No
Do you have any questions about what to do when you baby outgrows his current car safety seat?
No Yes
Is your water heater set so the temperature at the faucet is at or below 120°F/49°C?
Yes No
Doyoueverdrinkorcarryhotliquids(suchasteaorcoee)whenholdingyourbaby?
No Yes
Do you always keep one hand on your baby when changing diapers or clothing on a changing table, couch, or bed?
Yes No
Safe Sleep
Doyouhaveanydicultygettingyourbabytosleeponhisback?
No Yes
Have you moved your crib mattress to the lowest position to prevent falls?
Yes No
Does your baby sleep in your room?
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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4 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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