Fillable Bright Futures Previsit Questionnaire 10 Year Visit

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Bright Futures Previsit Questionnaire 10 Year Visit

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PAGE 1 OF 1
Bright Futures Previsit Questionnaire
10 Year Visit
The recommendations in this publication do not indicate an
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.
What would you like to talk about today?
Do you have any concerns, questions, or problems that you would like to discuss today?
We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.
School q How your child is doing in school q Homework q Bullying
Your Growing Child
q How your child feels about herself q Dealing with your child’s anger q Setting limits for your child
q Your child’s friends q Readiness for middle school q Your child’s sexuality q Puberty
Staying Healthy
q Your child’s weight q Your child’s body image q Eating breakfast q Limiting soft drinks
q Eating together as a family q Drinking enough water q Limiting high-fat food q 1 hour of physical activity daily
Healthy Teeth q Regular dentist visits q Brushing teeth twice daily q Flossing daily
q Bicycle and sports safety and helmets q Car safety q Swimming safety q Sunscreen
Safety
q Knowing your child’s friends and their families q Preventing cigarette, alcohol, and drug use q Gun safety
Questions About Your Child
Have any of your child’s relatives developed new medical problems since your last visit? If yes, please describe: q Yes q No q Unsure
Was your child born in a country at high risk for tuberculosis (countries other than the United States,
Canada, Australia, New Zealand, or Western Europe)?
q Yes q No q Unsure
Tuberculosis
Has your child traveled (had contact with resident populations) for longer than 1 week to a country
at high risk for tuberculosis?
q Yes q No q Unsure
Has a family member or contact had tuberculosis or a positive tuberculin skin test? q Yes q No q Unsure
Is your child infected with HIV? q Yes q No q Unsure
Does your child have parents or grandparents who have had a stroke or heart problem before age 55? q Yes q No q Unsure
Dyslipidemia
Does your child have a parent with elevated blood cholesterol (240 mg/dL or higher) or who is taking
cholesterol medication?
q Yes q No q Unsure
Does your child eat a strict vegetarian diet? q Yes q No q Unsure
Anemia If your child is a vegetarian, does your child take an iron supplement? q No q Yes q Unsure
Does your child’s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? q No q Yes q Unsure
Does your child have any special health care needs? q No q Yes, describe:
Have there been any major changes in your family lately? q Move q Job change q Separation q Divorce q Death in the family q Any other changes?
Does your child live with anyone who uses tobacco or spend time in any place where people smoke? q No q Yes
Your Growing and Developing Child
Do you have specific concerns about your child’s development, learning, or behavior? q No q Yes, describe:
Check off each of the following that are true for your child.
q Eats healthy meals and snacks q Participates in an after-school activity q Does an activity really well; describe:
q Has friends q Vigorously exercises for 1 hour a day
q Is doing well in school q Does chores when asked
q Feels good about himself q Getting chances to make own decisions
q Gets along with family
For us to provide your child with the best possible health care, we would like to know how things are going.
Please answer all of the questions. Thank you.
ACCOMPANIED BY/INFORMANT PREFERRED LANGUAGE DATE/TIME
DRUG ALLERGIES CURRENT MEDICATIONS
WEIGHT (%) HEIGHT (%) BMI (%) BLOOD PRESSURE
See growth chart.
Name
ID NUMBER
BIRTH DATE AGE
M F
Physical Examination
= NL
Bright Futures Priority Additional Systems
SKIN (tattoos, piercing, GENERAL APPEARANCE LUNGS
bruising, nevi)
HEAD HEART
BACK (scoliosis) EYES ABDOMEN
BREASTS/GENITALIA EARS SKIN
SEXUAL MATURITY
NOSE EXTREMITIES
RATING
MOUTH, THROAT, TEETH NEUROLOGIC
NECK
Abnormal findings and comments
Assessment
Well child
Anticipatory Guidance
Discussed and/or handout given
SCHOOL Expect preadolescent ORAL HEALTH
Show interest in school behaviors Dental visits twice a year
Quiet space for homework Answer questions and Brush teeth twice a day
Address bullying discuss puberty Floss teeth daily
DEVELOPMENT AND Safety rules with adults Wear mouth guards
MENTAL HEALTH
NUTRITION AND during sports
Encouraging independence PHYSICAL ACTIVITY SAFETY
and self-responsibility
Encourage proper Booster seat
Be a positive role model— nutrition Teach to swim/water
discuss respect, anger
60 minutes of physical safety
Know child’s friends and activity daily Sunscreen
importance of peers
Limit TV and screen Avoid tobacco, alcohol,
time drugs
Guns
Plan
Immunizations (See Vaccine Administration Record.)
Laboratory/Screening results: Vision Hearing
Referral to
Follow-up/Next visit
See other side
Print Name Signature
PROVIDER 1
PROVIDER 2
well child/9 to 10 years
History
Previsit Questionnaire reviewed Child has special health care needs
Child has a dental home
Concerns and questions None Addressed (see other side)
Follow-up on previous concerns None Addressed (see other side)
Interval history None Addressed (see other side)
Medication Record reviewed and updated
Social/Family History
See Initial History Questionnaire. No interval change
Family situation
After-school care: Yes No
Changes since last visit
Review of Systems
See Initial History Questionnaire and Problem List.
No interval change
Changes since last visit
Nutrition
Physical activity
Play time (60 min/d) Yes No
Screen time (<2 h/d) Yes No
School: Grade
Social interaction NL
Performance NL
Behavior NL
Attention NL
Homework NL
Parent/Teacher concerns None
Home: Cooperation NL
Parent-child interaction NL
Sibling interaction NL
Oppositional behavior None
Development (if not reviewed in Previsit Questionnaire)
Eats healthy meals and snacks Is doing well in school
Participates in an after-school activity Is getting chances to make own decisions
Has friends Feels good about self
Is vigorously active for 1 hour a day Does an activity really well; describe:
Has a caring/supportive family
HE0497
HE0497
The recommendations in this publication do not indicate an exclusive course of treatment or serve as
a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Copyright © 2010 American Academy of Pediatrics. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
9-235/0109
This American Academy of Pediatrics Visit Documentation Form is consistent with
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
Doing Well at School
• Tryyourbestatschool.It’simportanttohow
youfeelaboutyourself.
• Askforhelpwhenyouneedit.
• Joinclubsandteams,churchgroups,and
friendsforactivitiesafterschool.
• Tellkidswhopickonyouortrytohurtyouto
stopbotheringyou.Thenwalkaway.
• Telladultsyoutrustaboutbullies.
Playing It Safe
• Wearyourseatbeltatalltimesinthecar.
Useaboosterseatiftheseatbeltdoesnot
tyouyet.
• Sitinthebackseatuntilyouare13.Itisthe
safestplace.
• Wearyourhelmetforbiking,skating,and
skateboarding.
• Alwaysweartherightsafetyequipmentfor
youractivities.
• Neverswimalone.
• UsesunscreenwithanSPFof15orhigher
whenoutinthesun.
• Havefriendsoveronlywhenyourparentssay
it’sOK.
• Asktogohomeifyouareuncomfortable
withthingsatsomeoneelse’shouseora
party.
• Avoidbeingwithkidswhosuggestriskyor
harmfulthingstodo.
• Knowthatnoolderchildoradulthasthe
righttoasktoseeortouchyourprivate
parts,ortoscareyou.
Eating Well, Being Active
• Eatbreakfasteveryday.Ithelpslearning.
• Aimforeating5fruitsandvegetablesevery
day.
• Drink3cupsoflow-fatmilkorwaterinstead
ofsodapoporjuicedrinks.
• Limithigh-fatfoodsanddrinkssuchas
candies,snacks,fastfood,andsoftdrinks.
• Eatwithyourfamilyoften.
• Talkwithadoctorornurseaboutplansfor
weightlossorusingsupplements.
• Planandgetatleast1hourofactive
exerciseeveryday.
• LimitTVandcomputertimeto2hoursaday.
Healthy Teeth
• Brushyourteethatleasttwiceeachday,
morningandnight.
• Flossyourteetheveryday.
• Wearyourmouthguardwhenplayingsports.
Growing and Developing
• Askaparentortrustedadultquestionsabout
changesinyourbody.
• Talkingisagoodwaytohandleanger,
disappointment,worry,andfeelingsad.
• Everyonegetsangry.
• Staycalm.
• Listenandtalkthroughit.
• Trytounderstandtheotherperson’spoint
ofview.
• Don’tstayfriendswithkidswhoaskyouto
doscaryorharmfulthings.
• It’sOKtohaveup-and-downmoods,butif
youfeelsadmostofthetime,talktous.
• Knowwhyyousay“No!”todrugs,alcohol,
tobacco,andsex.
PAGE 1 OF 1
The recommendations in this publication do not indicate an
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.
Bright Futures Patient Handout
9 and 10 Year Visits
ORAL HEALTH
DEVELOPMENT AND MENTAL HEALTH
SAFETY
NUTRITION AND PHYSICAL ACTIVITY
SCHOOL
Staying Healthy
• Encourageyourchildtoeathealthy.
• Buyfat-freemilkandlow-fatdairyfoods,and
encourage3servingseachday.
• Include5servingsofvegetablesandfruitsat
mealsandforsnacksdaily.
• LimitTVandcomputertimeto2hoursaday.
• Encourageyourchildtobeactiveforatleast
1hourdaily.
• Eatasafamilyoften.
Safety
• Thebackseatisthesafestplacetorideina
caruntilyourchildis13yearsold.
• Useaboosterseatuntilthevehicle’ssafety
beltts.Thelapbeltcanbewornlowand
atontheupperthighs.Theshoulderbelt
canbewornacrosstheshoulderandthe
childcanbendatthekneeswhilesitting
againstthevehicleseatback.
• Teachyourchildtoswimandwatchherin
thewater.
• Yourchildneedssunscreen(SPF15or
higher)whenoutside.
• Yourchildneedsahelmetandsafetygear
forbiking,skating,in-lineskating,skiing,
snowmobiling,andhorsebackriding.
• Talktoyourchildaboutnotsmoking
cigarettes,usingdrugs,ordrinkingalcohol.
• Makeaplanforsituationsinwhichyourchild
doesnotfeelsafe.
• Gettoknowyourchild’sfriendsandtheir
families.
• Neverhaveaguninthehome.Ifnecessary,
storeitunloadedandlockedwiththe
ammunitionlockedseparatelyfromthegun.
Your Growing Child
• Beamodelforyourchildbysayingyouare
sorrywhenyoumakeamistake.
• Showyourchildhowtousehiswordswhen
heisangry.
• Teachyourchildtohelpothers.
• Giveyourchildchorestodoandexpectthem
tobedone.
• Giveyourchildhisownspace.
• Stillwatchyourchildandyourchild’sfriends
whentheyareplaying.
• Understandthatyourchild’sfriendsarevery
important.
• Answerquestionsaboutpuberty.
• Teachyourchildtheimportanceofdelaying
sexualbehavior.Encourageyourchildtoask
questions.
• Teachyourchildhowtobesafewithother
adults.
• Nooneshouldaskforasecrettobekept
fromparents.
• Nooneshouldasktoseeyourchild’s
privateparts.
• Noadultshouldaskforhelpwithhis
privateparts.
School
• Showinterestinschoolactivities.
• Ifyouhaveanyconcerns,askyourchild’s
teacherforhelp.
• Praiseyourchildfordoingthingswellat
school.
• Setaroutineandmakeaquietplacefor
doinghomework.
• Talkwithyourchildandherteacherabout
bullying.
Healthy Teeth
• Helpyourchildbrushteethtwiceaday.
• Afterbreakfast
• Beforebed
• Useapea-sizedamountoftoothpastewith
uoride.
• Helpyourchildosshisteethonceaday.
• Yourchildshouldvisitthedentistatleast
twiceayear.
• Encourageyourchildtoalwayswearamouth
guardtoprotectteethwhileplayingsports.
PoisonHelp:1-800-222-1222
Childsafetyseatinspection:
1-866-SEATCHECK;seatcheck.org
SCHOOL
ORAL HEALTH
SAFETY
DEVELOPMENT AND MENTAL HEALTH
NUTRITION AND PHYSICAL ACTIVITY
PAGE 1 OF 1
The recommendations in this publication do not indicate an
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.
Bright Futures Parent Handout
9 and 10 Year Visits
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Bright Futures Previsit Questionnaire 10 Year Visit

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