Fillable 5 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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5 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
5 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:
Is beginning to skip.
Walk on tiptoes when asked.
Catch a bounced ball with 2 hands.
Copy a triangle.
Draw a 6-part person.
Copy rst name.
Cut well with scissors.
Spread with a knife.
Dress and undress without help.
Urinate and have a bowel movement on her own.
Is dry through the day.
Tell a story of 2 sentences or more.
Follow directions for 4 individual prepositions, such
as on, under, behind, and in front of.
Play and interact with peers.
Answer “why” questions.
Count 5 objects.
Name 3 or more single numbers.
Name 4 or more letters out of
alphabetic order.
Write 2 or more letters.
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
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
5 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
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
Neighborhood and Family Violence (Bullying and Fighting)
Are there frequent reports of violence in your community or school?
No Yes
Has your child ever been bullied or hurt physically by someone?
No Yes
Has your child ever bullied or been aggressive with others?
No Yes
Food Security
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
Is there anyone in your child’s life whose alcohol or drug use concerns you?
No Yes
Emotional Security and Self-Esteem
Does your child usually seem happy?
Yes No
Are there things your child is really good at doing or is proud of?
Yes No
Connectedness With Family
Does your family get along well with each other?
Yes No
Does your family do things together?
Yes No
FAMILY RULES AND ROUTINES
Does your child have chores or responsibilities at home?
Yes No
Do you have clear rules and expectations for your child?
Yes No
When your child breaks the rules, are you consistent with consequences and discipline?
Yes No
Do you let your child know when she is being good?
Yes No
Does your child have problems dealing with angry feelings?
No Yes
Do you help your child control his anger?
Yes No
SCHOOL
Did your child attend a preschool program?
Yes No
Has your child started elementary school?
Yes No
Do you have any concerns about your child’s school experience?
No Yes
NA
PATIENT NAME: DATE:
Please print.
PAGE 3 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
5 YEAR VISIT
SCHOOL (CONTINUED)
Are you able to attend activities or functions at your child’s school?
Yes No
Is your child involved in after-school activities?
Yes No
Does your child receive any special education services?
No Yes
STAYING HEALTHY
Healthy Teeth
Does your child brush his teeth twice a day?
Yes No
Does your child see the dentist twice a year?
Yes No
Nutrition
Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.
No Yes
Does your child drink soda, juice, or other sugar-sweetened drinks?
No Yes
Does your child eat breakfast every day?
Yes No
Physical Activity
Is your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.
Yes No
How much time every day does your child spend watching TV or using computers, tablets, or smartphones (not counting
schoolwork)?
hours
Does your child have a TV or an Internet-connected device in his bedroom?
No Yes
Has your family made a family media use plan to help everyone balance time spent on media with other family and
personal activities?
Yes No
Does your child have trouble going to sleep or does he wake up during the night?
No Yes
Does your child have a regular bedtime?
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
Outdoor Safety
Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?
Yes No
Does your child know street safety habits, such as stopping at the curb, looking both ways, and never crossing the street
without a grown-up?
Yes No
Does your child know how to swim?
Yes No
Does your child know to always have an adult watching her in the water and never to swim alone?
Yes No
Does your child always use sunscreen when playing outside?
Yes No
Home Fire Safety
Do you have working smoke alarms installed on every level of your home?
Yes No
Do you have carbon monoxide detectors/alarms in your home?
Yes No
Do you have an emergency escape plan in case of re?
Yes No
Does your child know what to do if the re alarm rings?
Yes No
NA
NA
PATIENT NAME: DATE:
Please print.
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
5 YEAR VISIT
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
Have you talked with your child about gun safety?
Yes No
Harm From Adults
Have you taught your child that it is never OK for an adult to tell a child to keep secrets from her parents?
Yes No
Does your child know that it is never OK for an older child or an adult to ask to see his private parts?
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.
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5 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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