Fillable 9 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

Fill Online, Printable, Fillable, Blank 9 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

9 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

On average this form takes 28 minutes to complete

The 9 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE form is 3 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 106 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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. Child Development 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.
Use basic gestures, such as holding
her arms out to be picked up or waving
“bye-bye.”
Look for dropped objects.
Play games such as peekaboo and
pat-a-cake.
Turn consistently when his name is called.
Say, “Dada” or “Mama.”
Look around when you say things such as
“Where’s your bottle?” and “Where’s
your blanket?”
Copy sounds that you make.
Sit well without support.
Pull herself to a standing position.
Move easily between sitting and lying.
Crawl on hands and knees.
Pick up food and eat it.
Pickupsmallobjectswith3ngers
and a thumb.
Let go of objects on purpose.
Bang objects together.
BRIGHT FUTURES PREVISIT QUESTIONNAIRE
9 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
RISK ASSESSMENT
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
9 MONTH VISIT
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
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
YOUR FAMILY’S HEALTH AND WELL-BEING
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 the baby?
No Yes
Have you developed routines or other ways to take care of yourself?
Yes No
CARING FOR YOUR BABY
Do you have a regular bedtime routine for your baby?
Yes No
Does she wake up during the night?
No Yes
Is your baby learning new things?
Yes No
Does your baby have ways to tell you what he wants and needs?
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
Have you made a family media use plan to help you balance media use with other family activities?
Yes No
DISCIPLINE
Do you and your partner agree on how to handle your baby’s behavior?
Yes No
Do you limit the use of “No” to only the most important issues?
Yes No
If you have other children, do you let them help with the baby as much as they can?
Yes No
FEEDING YOUR BABY
Does your baby feed herself?
Yes No
Does your baby drink from a cup?
Yes No
Do you let your baby decide what and how much to eat?
Yes No
Doyougiveyourbabyfoodswithdierenttextures(suchaspureed,blended,mashed,chopped,orlumps)?
Yes No
If you are breastfeeding, are you planning on continuing?
Yes No
SAFETY
Car and Home Safety
Is your baby fastened securely in a rear-facing car safety seat in the back seat every time he rides in a vehicle?
Yes No
Do you have any habits or reminders that prevent you from ever leaving your baby in the car?
Yes No
Doyoukeepyourbabyawayfromthestove,replaces,andspaceheaters?
Yes No
NA
NA
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
9 MONTH VISIT
SAFETY (CONTINUED)
Car and Home Safety (continued)
Do you keep cleaners 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 she is in the bathtub?
Yes No
Doyoukeepfurnitureawayfromwindowsanduseoperablewindowguardsonsecond-oorandhigherwindows?
(Operablemeansthat,incaseofanemergency,anadultcanopenthewindow.)
Yes No
Do you have a gate at the top and bottom of all stairs in your home?
Yes No
Gun Safety
Does anyone in your home or the homes where your baby 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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

9 MONTH VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document