Fillable Bright Futures Previsit Questionnaire 2 Year Visit

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Bright Futures Previsit Questionnaire 2 Year Visit

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Bright Futures Previsit Questionnaire
2 Year 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.
Your Talking Child q How your child talks q Reading together
How Your Child Behaves
q Praising your child q Helping your child express feelings q Knowing how to give your child limited choices
q Playing with others q Helping your child follow directions q Your child’s weight
Toilet Training q Signs your child is ready to potty train q Helping your child potty train
Your Child and TV q How much TV is too much TV q Learning activities other than TV q How to be physically active as a family
Safety q Car safety seats q Bike helmets q Being safe outside 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
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
Dyslipidemia
Does your child have parents or grandparents who have had a stroke or heart problem before age 55? q Yes q No q Unsure
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
Anemia
Do you ever struggle to put food on the table? q Yes q No 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
Oral Health
Does your child have a dentist? 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 changes?
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.
PAGE 1 OF 2
PAGE 2 OF 2
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
2 Year 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 Stacks 5 or 6 small blocks q Throws a ball overhand q When talking, puts 2 words together, like “my book”
q Kicks a ball q Names 1 picture such as a cat, dog, or ball q Turns book pages 1 at a time
q Walks up and down stairs 1 step at a time q Jumps up q Plays pretend
alone while holding wall or railing q Copies things that you do q Plays alongside other children
q Can point to at least 2 pictures that you q Follows 2-step command
name when reading a book
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
Elimination: NL
Toilet training: Yes In process
Sleep: NL
Behavior/Temperament: NL
Physical activity
Play time (60 min/d) Yes No
Screen time (<2 h/d) Yes No
Development
Autism-specific screen NL Tool
Developmental Surveillance (if not reviewed in Previsit Questionnaire)
SOCIAL-EMOTIONAL COMMUNICATIVE PHYSICAL DEVELOPMENT
w Copies things that you do w When talking, puts 2 words w Stacks small blocks (5–6)
w Plays pretend together (eg, “my book”) w Kicks a ball
w Plays alongside other COGNITIVE w Walks up and down stairs
children w Names 1 picture (eg, cat, 1 step at a time alone while
dog, ball) holding wall or railing
w Follows 2-step commands w Throws a ball overhand
w Jumps up
w Turns book pages 1 at a time
Physical Examination
= NL
Bright Futures Priority Additional Systems
EYES (red reflex, GENERAL APPEARANCE HEART
cover/uncover test)
HEAD/FONTANELLE Femoral pulses
TEETH (caries, white spots, EARS/APPEARS TO HEAR ABDOMEN
staining)
NOSE GENITALIA
NEUROLOGIC MOUTH AND THROAT Male/Testes down
(coordination, language,
NECK Female
socialization)
LUNGS EXTREMITIES/HIPS
BACK
SKIN
Abnormal findings and comments
Assessment
Well child
Anticipatory Guidance
Discussed and/or handout given
ASSESSMENT OF LANGUAGE TOILET TRAINING SAFETY
DEVELOPMENT
w When child is ready w Car safety seat
w Model appropriate language w Plan for frequent toilet w Bike helmet
w Daily reading breaks w Supervise outside
w Following 1–2-step commands w Personal hygiene w Guns
w Listen and respond to child TV VIEWING
TEMPERAMENT AND BEHAVIOR w Limit TV viewing to no
w Praise, respect more than 1–2 hours/day
w Help express feelings w TV alternatives: reading,
w Self-expression games, singing
w Playing with other children w Encourage physical activity
Plan
Immunizations (See Vaccine Administration Record.)
Laboratory/Screening results: Lead
Referral to
Follow-up/Next visit
See other side
Print Name Signature
PROVIDER 1
PROVIDER 2
well child/2 years
ACCOMPANIED BY/INFORMANT PREFERRED LANGUAGE DATE/TIME
DRUG ALLERGIES CURRENT MEDICATIONS
WEIGHT (%) HEIGHT (%) HEAD CIRC (%) BMI (%)
See growth chart.
Name
ID NUMBER
TEMPERATURE BIRTH DATE AGE
M F
HE0491
HE0491
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.
9-63/Rev0109
This American Academy of Pediatrics Visit Documentation Form is consistent with
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
Your Talking Child
• Talk about and describe pictures in books
and the things you see and hear together.
• Parent-child play, where the child leads, is
the best way to help toddlers learn to talk.
• Read to your child every day.
• Your child may love hearing the same story
over and over.
• Ask your child to point to things as you read.
• Stop a story to let your child make an animal
sound or finish a part of the story.
• Use correct language; be a good model for
your child.
• Talk slowly and remember that it may take a
while for your child to respond.
Your Child and TV
• It is better for toddlers to play than watch TV.
• Limit TV to 1–2 hours or less each day.
• Watch TV together and discuss what you see
and think.
• Be careful about the programs and
advertising your young child sees.
• Do other activities with your child such as
reading, playing games, and singing.
• Be active together as a family. Make sure
your child is active at home, at child care,
and with sitters.
Safety
• Be sure your child’s car safety seat is
correctly installed in the back seat of all
vehicles.
• All children 2 years or older, or those
younger than 2 years who have outgrown
the rear-facing weight or height limit for
their car safety seat, should use a forward-
facing car safety seat with a harness for as
long as possible, up to the highest weight
or height allowed by their car safety seat’s
manufacturer.
• Everyone should wear a seat belt in the car.
Do not start the vehicle until everyone is
buckled up.
• Never leave your child alone in your home or
yard, especially near cars, without a mature
adult in charge.
• When backing out of the garage or driving
in the driveway, have another adult hold
your child a safe distance away so he is not
run over.
• Keep your child away from moving machines,
lawn mowers, streets, moving garage doors,
and driveways.
• Have your child wear a good-fitting helmet
on bikes and trikes.
• 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.
Toilet Training
• Signs of being ready for toilet training
• Dry for 2 hours
• Knows if she is wet or dry
• Can pull pants down and up
• Wants to learn
• Can tell you if she is going to have a bowel
movement
• Plan for toilet breaks often. Children use the
toilet as many as 10 times each day.
• Help your child wash her hands after toileting
and diaper changes and before meals.
• Clean potty chairs after every use.
• Teach your child to cough or sneeze into her
shoulder. Use a tissue to wipe her nose.
• Take the child to choose underwear when
she feels ready to do so.
How Your Child Behaves
• Praise your child for behaving well.
• It is normal for your child to protest being
away from you or meeting new people.
• Listen to your child and treat him with
respect. Expect others to as well.
• Play with your child each day, joining in
things the child likes to do.
• Hug and hold your child often.
• Give your child choices between 2 good
things in snacks, books, or toys.
• Help your child express his feelings and
name them.
• Help your child play with other children, but
do not expect sharing.
• Never make fun of the child’s fears or allow
others to scare your child.
• Watch how your child responds to new
people or situations.
What to Expect at Your
Child’s 2
1
/2 Year Visit
We will talk about
• Your talking child
• Getting ready for preschool
• Family activities
• Home and car safety
• Getting along with other children
Poison Help: 1-800-222-1222
Child safety seat inspection:
1-866-SEATCHECK; seatcheck.org
TOILET TRAINING
TEMPERAMENT AND BEHAVIOR
TELEVISION VIEWING
SAFETY
SAFETY ASSESSMENT OF LANGUAGE DEVELOPMENT
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, 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
2 Year Visit
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Completed 20 December 2021

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