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4 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
4 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.
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:
Go to the bathroom and have a bowel
movement by himself.
Dress and undress without much help.
Play make-believe.
Answer questions such as “What do you do when
you are cold?” and “When you are sleepy?”
Use 4-word sentences.
Speak so strangers can
understand 100% of what she says.
Draw pictures you recognize.
Follow simple rules when playing
board or card games.
Tell you a story from a book.
Skip on one foot.
Climb stairs, using one foot, then the other,
without support.
Draw a person with at least 3 body parts.
Draw a simple cross.
Unbutton and button medium-sized buttons.
Grasp a pencil with a thumb and ngers
instead of her st.
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 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
4 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
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
Is permanent housing a worry for you?
No Yes
Do you 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
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
Safety in the Community
Do you feel safe in your community?
Yes No
Do you have someone you can turn to if you are concerned about your child’s safety?
Yes No
Do you have connections to your community through faith groups, volunteer organizations, or recreational programs?
Yes No
Do you spend time with parents of other children in your community?
Yes No
GETTING READY FOR SCHOOL
Language Understanding and Fluency
Does your child clearly communicate his wants and needs to you and others?
Yes No
Do you respond to your child’s questions with short and simple answers?
Yes No
Do you give your child plenty of time to tell a story or answer a question?
Yes No
Do you talk, sing, and read together every day?
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
4 YEAR VISIT
GETTING READY FOR SCHOOL (CONTINUED)
Feelings
Is your child generally happy and active?
Yes No
Do you help your child say, “I’m sorry,” for hurting others’ feelings?
Yes No
Opportunities to Socialize With Other Children
Is your child interested in other children?
Yes No
Does your child have a chance to play with other children in playgroups or at preschool?
Yes No
Does your child have a best friend?
Yes No
Do you praise your child when she is good or has nished a task?
Yes No
Early Childhood Programs and Preschool
Does your child attend preschool?
Yes No
Are you happy with your child care or preschool arrangement?
Yes No
Do you visit your child’s preschool and participate in activities there?
Yes No
Readiness for School
Do you have any concerns about your child starting school in the coming year?
No Yes
Are you doing things to get your child ready for preschool? This could include reading together and going to the library, the
park, the zoo, and other places.
Yes No
HEALTHY HABITS
Nutrition
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
Daily Routines That Promote Health
Does your child sleep well?
Yes No
Do you have a regular bedtime and mealtime routines?
Yes No
Do you brush your child’s teeth twice a day with a pea-sized amount of uoridated toothpaste?
Yes No
LIMITING TV AND PROMOTING PHYSICAL ACTIVITY
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
Does your child play actively for at least 1 hour a day?
Yes No
Does your child play with other children?
Yes No
Are you physically active together as a family, such as going for walks or playing in the park?
Yes No
SAFETY
Car Safety
Is your child fastened securely in a car safety seat or belt-positioning booster seat in the back seat every time he
rides in a vehicle?
Yes No
Does everyone else in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
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 4 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
4 YEAR VISIT
SAFETY (CONTINUED)
Outdoor Safety
Do you watch your child closely when she plays outside, especially near streets and driveways?
Yes No
Are there swimming pools in your neighborhood?
No Yes
Are you planning to have your child learn to swim?
Yes No
Does your child always wear an US Coast Guard–approved life jacket when on a boat?
Yes No
Does your child always use sunscreen when he plays outside?
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
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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4 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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