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6 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 and Oral Health Risk Assessment are also part of this
visit. Thank you.
Check o each of the tasks that your baby is able to do.
Patorsmileathisreection.
Look when you call her name.
Babble.
Roll over from his back to his tummy.
Sitbrieywithoutsupport.
Make sounds such as “ga,” “ma,” and “ba.”
Pass a toy from one hand to another.
Rakesmallobjectswith4ngers.
Bang small objects on a surface.
BRIGHT FUTURES PREVISIT QUESTIONNAIRE
6 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:
Doyouhavespecicconcernsaboutyourbaby’sdevelopment,learning,orbehavior? No Yes, describe:
PATIENT NAME: DATE:
Please print.
Does your baby 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
PAGE 2 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
6 MONTH VISIT
RISK ASSESSMENT
Hearing
Do you have concerns about how your baby hears?
No Yes Unsure
Lead
Doesyourbaby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 that was renovated in the past 6 months?
No Yes Unsure
Oral health
Doesyourbaby’sprimarywatersourcecontainuoride?
Yes No Unsure
Tuberculosis
Was your baby 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 baby had close contact with a person who has tuberculosis disease or who has
had a positive tuberculosis test result?
No Yes Unsure
Is your baby infected with HIV?
No Yes Unsure
Vision
Do you have concerns about how your baby sees?
No Yes Unsure
Do your baby’s eyes appear unusual or seem to cross?
No Yes Unsure
Do your baby’s eyelids droop or does one eyelid tend to close?
No Yes Unsure
Have your baby’s eyes ever been injured?
No Yes Unsure
ANTICIPATORY GUIDANCE
YOUR FAMILY’S HEALTH AND WELL-BEING
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 the baby, such as a crib, a car safety seat, and diapers?
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
Family Relationships and Support
Do you have people you can go to when you need help with your family?
Yes No
Do you have child care or a reliable person to care for your baby?
Yes No
CARING FOR YOUR BABY
Your Baby’s Development
Is your baby learning new things?
Yes No
Is your baby adapting to new situations, people, and places?
Yes No
Does your baby have ways to tell you what he wants and needs?
Yes No
Does your baby respond when you look at books together?
Yes No
Is a TV, computer, tablet, or smartphone on in the background while 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
Does your baby have a regular daily schedule for feeding, napping, playing, and sleeping?
Yes No
Is your baby learning to go to sleep by himself?
Yes No
Can your baby calm herself?
Yes No
Do you have ways to help your baby calm himself if he cannot do it himself?
Yes No
How are things going for you, your baby, and your family?
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 3 of 3
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
6 MONTH VISIT
HEALTHY TEETH
Do you give your baby a bottle in her crib?
No Yes
FEEDING YOUR BABY
General Information
What are you feeding your baby?
Check all that apply: ______ Breast milk ______ Formula ______ Both
Are you feeding your baby any drinks or foods besides breast milk or formula?
Check all that apply: ____ Water ____ Juice ____ Cereal ____ Meats ____ Fruits ____ Vegetables ____ Other foods
Does your baby let you know when he likes or dislikes new foods that you have introduced?
Yes No
Do you wash vegetables and fruits before serving them to your baby and family?
Yes No
If you are breastfeeding, answer these questions.
Are you planning on continuing?
Yes No
Do you have questions about pumping and storing your breast milk?
No Yes
Are you still giving your baby vitamin D drops and iron drops?
Yes No
If you are formula feeding, or providing formula supplementation, answer these questions.
Areyouusingiron-fortiedformula?
Yes No
Do you have any questions or concerns about the formula, such as how much it costs or how to prepare it?
No Yes
SAFETY
General Information
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
Are you having any problems with your 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 have barriers around space heaters, woodstoves, and kerosene heaters?
Yes No
Do you put a hat on your baby and apply sunscreen on her when you go outside?
Yes No
Do you keep household cleaners, chemicals, and medicines locked up and out of your baby’s sight and reach?
Yes No
Do you always stay within arm’s reach of your baby when he is in the bath?
Yes No
Do you always keep one hand on your baby when changing diapers or clothing on a changing table, couch, or bed?
Yes No
Do you have a gate at the top and bottom of all stairs in your home?
Yes No
Safe Sleep
Do you continue to place your baby onto her back for sleep?
Yes No
Does your baby sleep in a crib?
Yes No
PATIENT NAME: DATE:
Please print.
NA
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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6 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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