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Bright Futures Previsit Questionnaire
12 Month Visit
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.
Family Support q Ways to manage your child’s behavior q Finding time for yourself q Parent/family community activities
Establishing Routines q Nap time routines q Bedtime routines q Brushing teeth q Starting family traditions
Feeding Your Child
q Using a spoon and cup q Healthy food choices q How many meals or snacks a day
q How much your child should eat q Change in appetite and growth q Your child’s weight
Finding a Dentist q Your child’s first dental checkup q Brushing teeth twice daily q Finger sucking, pacifiers, and bottles
Safety
q Home safety indoors and outdoors q Car safety seats q Water safety q Gun safety
q Older siblings watching your child q Foods that might cause choking
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
Hearing
Do you have concerns about how your child hears? q Yes q No q Unsure
Do you have concerns about how your child speaks? q Yes q No q Unsure
Do you have concerns about how your child sees? q Yes q No q Unsure
Does your child hold objects close when trying to focus? q Yes q No q Unsure
Vision Do your child’s eyes appear unusual or seem to cross, drift, or be lazy? q Yes q No q Unsure
Do your child’s eyelids droop or does one eyelid tend to close? q Yes q No q Unsure
Have your child’s eyes ever been injured? q Yes q No q Unsure
Does your child have a sibling or playmate who has or had lead poisoning? q Yes q No q Unsure
Lead
Does your child live in or regularly visit a house or child care facility built before 1978 that is being
or has recently been (within the past 6 months) renovated or remodeled?
q Yes q No q Unsure
Does your child live in or regularly visit a house or child care facility built before 1950? 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
Oral Health
Do you know a dentist to whom you can bring your child? q No q Yes q Unsure
Does your child’s primary water source contain fluoride? 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 problems?
Does your child live with anyone who uses tobacco or spend time in any place where people smoke? q No q Yes
For us to provide you and 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.
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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 Previsit Questionnaire
12 Month Visit
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 tasks that your child is able to do.
q Bangs toys together q Tries to make the same sounds you do
q Waves bye-bye q Looks at things you are looking at
q Tries to do what you do q Cries when you leave
q Stands alone q Hands you a book to read
q Drinks from a cup q Follows simple directions
q Speaks 1 to 2 words q Plays peekaboo
q Babbles
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
Parents working outside home: Mother Father
Child care: Yes No Type
Changes since last visit
Review of Systems
See Initial History Questionnaire and Problem List.
No interval change
Changes since last visit
Nutrition: Breast milk Minutes per feeding
Hours between feeding Feedings per 24 hours
Formula Ounces per feeding
Source of water Vitamins/Fluoride
Elimination: NL
Sleep: NL
Behavior: NL
Activity (playtime, no TV): NL
Development (if not reviewed in Previsit Questionnaire)
SOCIAL-EMOTIONAL COMMUNICATIVE PHYSICAL
w Waves bye-bye w Speaks 1–2 words DEVELOPMENT
w Tries to do what you do w Babbles w Bangs toys together
w Cries when you leave w Tries to make the same w Pulls to stand
w Plays peekaboo sounds you do w Stands alone
w Hands you a book to read w Looks at things you are w Drinks from a cup
looking at
COGNITIVE
w Follows simple directions
ACCOMPANIED BY/INFORMANT PREFERRED LANGUAGE DATE/TIME
DRUG ALLERGIES CURRENT MEDICATIONS
WEIGHT (%) LENGTH (%) WEIGHT FOR LENGTH (%) HEAD CIRC (%)
See growth chart.
Name
ID NUMBER
TEMPERATURE BIRTH DATE AGE
M F
Physical Examination
= NL
Bright Futures Priority Additional Systems
EYES (red reflex, GENERAL APPEARANCE EXTREMITIES/HIPS
cover/uncover test)
HEAD/FONTANELLE LUNGS
NEUROLOGIC (tone, EARS/APPEARS TO HEAR ABDOMEN
strength, gait)
NOSE BACK
TEETH (caries, white spots, MOUTH AND THROAT SKIN
staining)
HEART
GENITALIA Femoral pulses
MALE/TESTES DOWN
FEMALE
Abnormal findings and comments
Assessment
Well child
Anticipatory Guidance
Discussed and/or handout given
FAMILY SUPPORT FEEDING AND APPETITE SAFETY
w Time for self/partner CHANGES w Car safety seat
w Community activities w Self-feeding w Poisons
w Age-appropriate discipline w Consistent meals/snacks w Water
ESTABLISHING ROUTINES w Variety of nutritious foods w No supervision
w Family traditions w Iron-fortified formula by young children
w Nap and bedtime ESTABLISHING A DENTAL HOME w Sharp objects
w First dentist visit w Guns
w Brush teeth twice a day w Home safety
w Limit bottle use (water only) w Falls
w No bottle in bed
Plan
Immunizations (See Vaccine Administration Record.)
Laboratory/Screening results: Hgb/Hct Lead Other
Referral to
Follow-up/Next visit
See other side
Print Name Signature
PROVIDER 1
PROVIDER 2
well child/12 months
HE0488
HE0488
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.
9-60/Rev1208
This American Academy of Pediatrics Visit Documentation Form is consistent with
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
Family Support
Try not to hit, spank, or yell at your child.
Keep rules for your child short and simple.
Use short time-outs when your child is
behaving poorly.
Praise your child for good behavior.
Distract your child with something he likes
during bad behavior.
Play with and read to your child often.
Make sure everyone who cares for your child
gives healthy foods, avoids sweets, and uses
the same rules for discipline.
Make sure places your child stays are safe.
Think about joining a toddler playgroup or
taking a parenting class.
Take time for yourself and your partner.
Keep in contact with family and friends.
Establishing Routines
Your child should have at least one nap.
Space it to make sure your child is tired for
bed.
Make the hour before bedtime loving and
calm.
Have a simple bedtime routine that includes
a book.
Avoid having your child watch TV and videos,
and never watch anything scary.
Be aware that fear of strangers is normal and
peaks at this age.
Respect your child’s fears and have strangers
approach slowly.
Avoid watching TV during family time.
Start family traditions such as reading or
going for a walk together.
Feeding Your Child
Have your child eat during family mealtime.
Be patient with your child as she learns to
eat without help.
Encourage your child to feed herself.
Give 3 meals and 2–3 snacks spaced evenly
over the day to avoid tantrums.
Make sure caregivers follow the same ideas
and routines for feeding.
Use a small plate and cup for eating and
drinking.
Provide healthy foods for meals and snacks.
Let your child decide what and how much
to eat.
End the feeding when the child stops eating.
Avoid small, hard foods that can cause
chokingnuts, popcorn, hot dogs, grapes,
and hard, raw veggies.
Safety
Have your child’s car safety seat rear-facing
until your child is 2 years of age or until she
reaches the highest weight or height allowed
by the car safety seat’s manufacturer.
Lock away poisons, medications, and lawn
and cleaning supplies. Call Poison Help
(1-800-222-1222) if your child eats nonfoods.
Keep small objects, balloons, and plastic
bags away from your child.
Place gates at the top and bottom of stairs
and guards on windows on the second
floor and higher. Keep furniture away from
windows.
Lock away knives and scissors.
Only leave your toddler with a mature adult.
Near or in water, keep your child close
enough to touch.
Make sure to empty buckets, pools, and tubs
when done.
Never have a gun in the home. If you must
have a gun, store it unloaded and locked
with the ammunition locked separately from
the gun.
Finding a Dentist
Take your child for a first dental visit by
12 months.
Brush your child’s teeth twice each day.
With water only, use a soft toothbrush.
If using a bottle, offer only water.
What to Expect at Your
Child’s 15 Month Visit
We will talk about
Your child’s speech and feelings
Getting a good night’s sleep
Keeping your home safe for your child
Temper tantrums and discipline
Caring for your child’s teeth
Poison Help: 1-800-222-1222
Child safety seat inspection:
1-866-SEATCHECK; seatcheck.org
SAFETY
SAFETYESTABLISHING A DENTAL HOME
ESTABLISHING ROUTINES
FEEDING AND APPETITE CHANGES
FAMILY SUPPORT
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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, Updated 8/11. 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
12 Month Visit
Here are some suggestions from Bright Futures experts that may be of value to your family.