Fillable 9 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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9 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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BRIGHT FUTURES PREVISIT QUESTIONNAIRE
9 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 items that are true for your child.
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:
Shows the ability to get along with others and control his emotions
Chooses to eat healthy foods and participate in physical activity every day
Forms caring, supportive relationships with family members, other adults, and peers
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
9 YEAR VISIT
Anemia
Does your child’s diet include iron-rich foods, such as meat, iron-fortied cereals, or beans?
Yes No Unsure
Does your child eat a vegetarian diet (does not eat red meat, chicken, sh, or seafood)?
No Yes Unsure
If your child is a vegetarian (does not eat red meat, chicken, sh, or seafood), does your child
take an iron supplement?
Yes No Unsure
Do you ever struggle to put food on the table?
No Yes Unsure
Hearing
Do you have concerns about how your child hears?
No Yes Unsure
Do you have concerns about how your child speaks?
No Yes Unsure
Oral health
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
Vision
Do you have concerns about how your child sees?
No Yes Unsure
Has your child ever failed a school vision screening test?
No Yes Unsure
Does your child tend to squint?
No Yes Unsure
YOUR FAMILY’S HEALTH AND WELL-BEING
Neighborhood and Family Violence
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 felt excluded or not a part of any group of friends?
No Yes
Has your child ever told you she was touched in a way that made her uncomfortable or on her private parts?
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
Tobacco, E-cigarettes, Alcohol, and Drugs
Is there anyone in your child’s life whose alcohol or drug use concerns you?
No Yes
Do any of your child’s friends smoke, use or vape e-cigarettes, drink alcohol or beer, or use drugs?
No Yes
Harm From the Internet
Do you know about your child’s Internet use?
Yes No
Do you have rules for the Internet?
Yes No
Have you installed an Internet safety lter on your computers, tablets, and smartphones?
Yes No
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
Does your child have the chance to help others at home, at school, or in your community?
Yes No
PATIENT NAME: DATE:
Please print.
PAGE 3 of 4
American Academy of Pediatrics | Bright Futures | https://brightfutures.aap.org
9 YEAR VISIT
YOUR FAMILY’S HEALTH AND WELL-BEING (CONTINUED)
Connectedness With Family and Peers
Do your family members get along well with each other?
Yes No
Does your family do things together?
Yes No
Does your child have chores or responsibilities at home?
Yes No
Does your child have friends at school or in your neighborhood?
Yes No
YOUR GROWING CHILD
Temper Problems, Setting Reasonable Limits, and Friends
Has your child experienced any recent stresses at home or in school?
No Yes
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 help your child control his anger, deal with worries, and solve problems?
Yes No
Have you and your child talked about how to say no to smoking, alcohol, and drug use?
Yes No
Onset of Puberty and Sexual Safety
Have you talked with your child about the body changes that occur during puberty?
Yes No
Have you discussed privacy and body safety with your child?
Yes No
Have you and your child talked about sex?
Yes No
Does your child know to tell a trusted adult if someone touches her private parts or if someone encourages her to do other
things that make her uncomfortable or she knows are wrong?
Yes No
SCHOOL
Do you have concerns about your child’s school experience?
No Yes
Has your child missed more than 2 days of school in any month?
No Yes
Does your child have any diculties at school or get extra help in any subjects?
No Yes
Does your child participate in activities outside of school?
Yes No
STAYING HEALTHY
Healthy Teeth
Does your child have a dentist?
Yes No
Does your child brush and oss his teeth every day?
Yes No
Does your child use a mouth guard when playing contact sports?
Yes No
Does your child regularly drink soda, juice, or other sugar-sweetened drinks?
No Yes
Nutrition
Do you have any concerns about your child’s weight?
No Yes
Do you have any concerns about her eating? This includes drinking enough milk and eating vegetables and fruits.
No Yes
Do you eat family meals together?
Yes No
Do you hear your child talking about how he looks or dieting?
No Yes
Physical Activity
Is your child physically active at least 1 hour a day? This includes running, playing sports, or active play with friends.
Yes No
Do you have any concerns about your child’s physical activity level, such as it being either too much or too little?
No Yes
Does your child have trouble going to sleep or does she wake up during the night?
No Yes
How much time every day does your child spend watching TV, playing video games, or using computers, tablets, or
smartphones (not counting schoolwork)?
hours
Does your child have a TV or an Internet-connected device in her 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
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
9 YEAR VISIT
SAFETY
Car Safety
Does your child always sit in a belt-positioning booster seat or lap and shoulder seat belt in the back seat every time he
rides in a vehicle?
Yes No
Does everyone in the vehicle always use a lap and shoulder seat belt?
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 how to swim?
Yes No
Does your child know to always have an adult watching him in the water and never to swim alone?
Yes No
Does your child always use sunscreen when playing outside?
Yes No
Knowing Your Child’s Friends and Their Families
Do you know your child’s friends and their families?
Yes No
Does your child know how to get help in an emergency if you are not there?
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
Have you talked with your child about gun safety?
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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9 YEAR VISIT BRIGHT FUTURES PREVISIT QUESTIONNAIRE

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Completed 22 June 2022

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