Fillable Bright Futures Previsit Questionnaire Early Adolescent Visits

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Bright Futures Previsit Questionnaire Early Adolescent Visits

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Bright Futures Previsit Questionnaire
Early Adolescent Visits
What would you like to talk about today?
Do you have any concerns, questions, or problems that you would like to discuss today?
What changes or challenges have there been at home since last year?
Do you live with anyone who uses tobacco or spend time in any place where people smoke? q No q Yes
We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.
Your Growing and Changing Body
q Teeth q Appearance or body image q How you feel about yourself q Healthy eating
q Good ways to be active q How your body is changing q Your weight
School and Friends
q Your relationship with your family q Your friends q How you are doing in school q Girlfriend or boyfriend
q Organizing your time to get things done
How You Are Feeling
q Dealing with stress q Keeping under control q Sexuality q Feeling sad q Feeling anxious
q Feeling irritable
Healthy Behavior Choices
q Smoking cigarettes q Drinking alcohol q Using drugs q Pregnancy q Sexually transmitted infections (STIs)
q Decisions about sex and drugs
Violence and Injuries
q Car safety q Using a helmet or protective gear q Keeping yourself safe in a risky situation q Gun safety
q Bullying or trouble with other kids q Not riding in a car with a drinking driver
Questions
Dyslipidemia Do you smoke cigarettes? q Yes q No q Unsure
Alcohol or
Have you ever had an alcoholic drink? q Yes q No q Unsure
Drug Use
Have you ever used marijuana or any other drug to get high? q Yes q No q Unsure
STIs Have you ever had sex (including intercourse or oral sex)? q Yes q No q Unsure
Anemia
Does your diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? q No q Yes q Unsure
Have you ever been diagnosed with iron deficiency anemia? q Yes q No q Unsure
For Females Only
Anemia
Do you have excessive menstrual bleeding or other blood loss? q Yes q No q Unsure
Does your period last more than 5 days? q Yes q No q Unsure
Growing and Developing
Check off all of the items that you feel are true for you.
q I engage in behavior that supports a healthy lifestyle, such as eating healthy foods, being active, and keeping myself safe.
q I feel I have at least one responsible adult in my life who cares about me and who I can go to if I need help.
q I feel like I have at least one friend or a group of friends with whom I am comfortable.
q I help others on my own or by working with a group in school, a faith-based organization, or the community.
q I am able to bounce back from life’s disappointments.
q I have a sense of hopefulness and self-confidence.
q I have become more independent and made more of my own decisions as I have become older.
q I feel that I am particularly good at doing a certain thing like math, soccer, theater, cooking, or hunting. Describe:
For us to provide you with the best possible health care, we would like to get to know you better and know how things are going for you.
Our discussions with you are private. We hope you will feel free to talk openly with us about yourself and your health. Information is not
shared with other people without your permission unless we are concerned that someone is in danger. Thank you for your time.
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.
PAGE 1 OF 2
Bright Futures Previsit Questionnaire
Older Child/Early Adolescent Visits—For Parents
What would you like to talk about today?
Do you have any concerns, questions, or problems that you would like to discuss today?
What changes or challenges have there been at home since last year?
Does your child have any special health care needs? q No q Yes, describe:
Does your child live with anyone who uses tobacco or spend time in any place where people smoke? q No q Yes, describe:
How many hours per day does your child watch TV, play video games, and use the computer (not for schoolwork)?
Questions About Your Child
Does your child complain that the blackboard has become difficult to see? q Yes q No q Unsure
Has your child ever failed a school vision screening test? q Yes q No q Unsure
Vision Does your child hold books close to read? q Yes q No q Unsure
Does your child have trouble recognizing faces at a distance? q Yes q No q Unsure
Does your child tend to squint? q Yes q No q Unsure
Does your child have a problem hearing over the telephone? q Yes q No q Unsure
Does your child have trouble following the conversation when 2 or more people are talking at the same time? q Yes q No q Unsure
Hearing Does your child have trouble hearing with a noisy background? q Yes q No q Unsure
Does your child ask people to repeat themselves? q Yes q No q Unsure
Does your child misunderstand what others are saying and respond inappropriately? 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
Has your child traveled (had contact with resident populations) for longer than 1 week to a country
Tuberculosis
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 an elevated blood cholesterol (240 mg/dL or higher) or who is taking
cholesterol medication?
q Yes q No q Unsure
Anemia
Does your child’s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? q No q Yes q Unsure
Has your child ever been diagnosed with iron deficiency anemia? q Yes q No q Unsure
For us to provide your child with the best possible health care, we would like to know how things are going.
Thank you.
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
Older Child/Early Adolescent Visits—For Parents
For Females Only
Anemia
Does your child have excessive menstrual bleeding or other blood loss? q Yes q No q Unsure
Does your child’s period last more than 5 days? q Yes q No q Unsure
Your Growing and Developing Child
Check off all of the items that you feel are true for your child.
q My child engages in behavior that supports a healthy lifestyle, such as eating healthy foods, being active, and keeping herself safe.
q My child has at least one responsible adult in his life who cares about him and to whom he can go to if he needs help.
q My child has at least one friend or a group of friends with whom she is comfortable.
q My child helps others individually or by working with a group in school, a faith-based organization, or the community.
q My child is able to bounce back from life’s disappointments.
q My child has a sense of hopefulness and self-confidence.
q My child has become more independent and made more of his own decisions as he has become older.
q My child is particularly good at doing a certain thing like math, soccer, theater, cooking, or hunting. Describe:
ACCOMPANIED BY/INFORMANT PREFERRED LANGUAGE DATE/TIME
DRUG ALLERGIES CURRENT MEDICATIONS
WEIGHT (%) HEIGHT (%) BMI (%) BLOOD PRESSURE
Visit with:
Teen alone Parent(s) alone Mother Father Teen with parents
Name
ID NUMBER
BIRTH DATE AGE
M F
Physical Examination
= NL
Bright Futures Priority Additional Systems
SKIN GENERAL APPEARANCE TEETH
BACK/SPINE HEAD LUNGS
BREASTS EYES HEART
GENITALIA EARS ABDOMEN
SEXUAL MATURITY RATING
NOSE EXTREMITIES
MOUTH AND THROAT NEUROLOGIC
NECK
Abnormal findings and comments
Assessment
Well teen
Anticipatory Guidance
Discussed and/or handout given
PHYSICAL GROWTH AND Family time VIOLENCE AND
DEVELOPMENT
Age-appropriate limits INJURY PREVENTION
Brush/Floss teeth Friends Seat belts, no ATV
Regular dentist visits EMOTIONAL WELL-BEING Guns
Body image Decision-making Safe dating
Balanced diet Dealing with stress Conflict resolution
Limit TV Mental health concerns Bullying
Physical activity Sexuality/Puberty Sport helmets
SOCIAL AND ACADEMIC RISK REDUCTION Protective gear
COMPETENCE
Tobacco, alcohol, drugs
Help with homework when needed Prescription drugs
Encourage reading/school Know friends and activities
Community involvement Sex
Plan
Immunizations (See Vaccine Administration Record.)
Laboratory/Screening results: Vision
Referral to
Follow-up/Next visit
See other side
Print Name Signature
PROVIDER 1
PROVIDER 2
well child/11 to 14 years
History
Previsit Questionnaire reviewed Teen has special health care needs
Teen 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)
Menarche: Age Regularity
Menstrual problems
Medication Record reviewed and updated
Social/Family History
See Initial History Questionnaire. No interval change
Changes since last visit
Teen lives with
Relationship with parents/siblings
Risk Assessment
If not reviewed in Supplemental Questionnaire
(Use other side if risks identified.)
HOME
Eats meals with family Yes No
Has family member/adult to turn to for help Yes No
Is permitted and is able to make independent decisions Yes No
EDUCATION
Grade
Performance NL
Behavior/Attention NL
Homework NL
EATING
Eats regular meals including adequate fruits and vegetables Yes No
Drinks non-sweetened liquids Yes No
Calcium source Yes No
Has concerns about body or appearance Yes No
ACTIVITIES
Has friends Yes No
At least 1 hour of physical activity/day Yes No
Screen time (except for homework) less than 2 hours/day Yes No
Has interests/participates in community activities/volunteers Yes No
DRUGS (Substance use/abuse)
Uses tobacco/alcohol/drugs Yes No
SAFETY
Home is free of violence Yes No
Uses safety belts/safety equipment Yes No
Has peer relationships free of violence Yes No
SEX
Has had oral sex Yes No
Has had sexual intercourse (vaginal, anal) Yes No
SUICIDALITY/MENTAL HEALTH
Has ways to cope with stress Yes No
Displays self-confidence Yes No
Has problems with sleep Yes No
Gets depressed, anxious, or irritable/has mood swings Yes No
Has thought about hurting self or considered suicide Yes No
Other
HE0498
Psychosocial Risks
Confidential (To be completed confidentially for teens with identified risk)
Home
Relationship with parents/guardians
Violence in home
Teen’s concerns
Autonomy
Counseling/Recommendations
Education
Teen’s concerns
Social interactions
Conflicts
Counseling/Recommendations
Eating
Usual diet
Attempts to lose weight by dieting, laxatives, or self-induced vomiting
Regular meals (includes breakfast, limits fast food)
Counseling/Recommendations
Activities
Clubs/Extracurricular
Music/Art
Sports
Religious/Community
TV/Electronics hours/day
Gangs
Counseling/Recommendations
CRAFFT used with permission from Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G.
Validity of the CRAFFT substance abuse screening test among adolescent clinic patients.
Arch Pediatr Adolesc Med. 2002;156:607–614
HEEADSSS used with permission from Goldenring JM, Rosen DS. Getting into adolescent
heads: an essential update. Contemp Pediatr. 2004;21:64–90
This American Academy of Pediatrics Visit Documentation Form is consistent with Bright
Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.
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.
Drugs (Substance Use/Abuse)
Tobacco use
Alcohol
Drugs (street/prescription)
Steroids
CRAFFT (+2 indicates need for follow-up)
C – Have you ever ridden in a CAR driven by someone (including yourself)
who was “high” or had been using alcohol or drugs? Yes No
R – Do you ever use alcohol or drugs to RELAX, feel better about yourself,
or fit in? Yes No
A – Do you ever use alcohol or drugs while you are by yourself, ALONE?
Yes No
F – Do you ever FORGET things you did while using alcohol or drugs?
Yes No
F – Do your family or FRIENDS ever tell you that you should cut down on
your drinking or drug use? Yes No
T – Have you gotten into TROUBLE while you were using alcohol or drugs?
Yes No
Counseling/Recommendations
Safety
Bullying
Guns
Dating violence
Passenger safety
Sports/recreation safety
Counseling/Recommendations
Sex
Oral sex Yes No
Has had sexual intercourse (vaginal, anal) Yes No
Age of onset of sexual activity
Number of partners Gender of partners Male Female
Sexual orientation
Condom use Contraception
Previous pregnancy No Yes
Previous STI No Yes
Laboratory/Screening results
Pregnancy test Pap smear
Chlamydia/Gonorrhea, source Syphilis HIV
STI screening laboratory results (specify)
Counseling/Recommendations
Suicidality/Mental Health
Depression No Yes—when?
Anxiety No Yes—when?
Suicide ideation No Yes—when?
Suicide attempts No Yes—when?
History of psychologic counseling No Yes—when?
Other mental health diagnosis
Counseling/Recommendations
Confidentiality discussed With teen With parent(s)
HE0498
9-219/0109
Your Growing and Changing
Body
• Brushyourteethtwiceadayandossonce
aday.
• Visitthedentisttwiceayear.
• Wearyourmouthguardwhenplayingsports.
• Eat3healthymealsaday.
• Eatingbreakfastisveryimportant.
• Considerchoosingwaterinsteadofsoda.
• Limithigh-fatfoodsanddrinkssuchas
candy,chips,andsoftdrinks.
• Trytoeathealthyfoods.
• 5fruitsandvegetablesaday
• 3cupsoflow-fatmilk,yogurt,orcheese
• Eatwithyourfamilyoften.
• Aimfor1hourofmoderatelyvigorous
physicalactivityeveryday.
• TrytolimitwatchingTV,playingvideogames,
orplayingonthecomputerto2hoursaday
(outsideofhomeworktime).
• Beproudofyourselfwhenyoudosomething
good.
Healthy Behavior Choices
• Findfun,safethingstodo.
• Talktoyourparentsaboutalcoholanddrug
use.
• Supportfriendswhochoosenottouse
tobacco,alcohol,drugs,steroids,ordietpills.
• Talkaboutrelationships,sex,andvalueswith
yourparents.
• Talkaboutpubertyandsexualpressureswith
someoneyoutrust.
• Followyourfamily’srules.
How You Are Feeling
• Figureouthealthywaystodealwithstress.
• Spendtimewithyourfamily.
• Alwaystalkthroughproblemsandneveruse
violence.
• Lookforwaystohelpoutathome.
• It’simportantforyoutohaveaccurate
informationaboutsexuality,yourphysical
development,andyoursexualfeelings.
Pleaseconsideraskingmeifyouhaveany
questions.
School and Friends
• Tryyourbesttoberesponsibleforyour
schoolwork.
• Ifyouneedhelporganizingyourtime,ask
yourparentsorteachers.
• Readoften.
• Findactivitiesyouarereallyinterestedin,
suchassportsortheater.
• Findactivitiesthathelpothers.
• Spendtimewithyourfamilyandhelpat
home.
• Stayconnectedwithyourparents.
Violence and Injuries
• Alwayswearyourseatbelt.
• DonotrideATVs.
• Wearprotectivegearincludinghelmets
forplayingsports,biking,skating,and
skateboarding.
• Makesureyouknowhowtogethelpifyou
arefeelingunsafe.
• Neverhaveaguninthehome.Ifnecessary,
storeitunloadedandlockedwiththe
ammunitionlockedseparatelyfromthegun.
• Figureoutnonviolentwaystohandleangeror
fear.Fightingandcarryingweaponscanbe
dangerous.Youcantalktomeabouthowto
avoidthesesituations.
• Healthydatingrelationshipsarebuilton
respect,concern,anddoingthingsbothof
youliketodo.
SOCIAL AND ACADEMIC COMPETENCE
VIOLENCE AND INJURY PREVENTION
RISK REDUCTION
EMOTIONAL WELL-BEING
PHYSICAL GROWTH AND 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. 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
Early Adolescent Visits
Your Growing and Changing
Child
• Talkwithyourchildabouthowherbodyis
changingwithpuberty.
• Encourageyourchildtobrushhisteethtwice
adayandossonceaday.
• Helpyourchildgettothedentisttwicea
year.
• Servehealthyfoodandeattogetherasa
familyoften.
• Encourageyourchildtoget1hourof
vigorousphysicalactivityeveryday.
• Helpyourchildlimitscreentime(TV,video
games,orcomputer)to2hoursaday,not
includinghomeworktime.
• Praiseyourchildwhenshedoessomething
well,notjustwhenshelooksgood.
Healthy Behavior Choices
• Helpyourchildndfun,safethingstodo.
• Makesureyourchildknowshowyoufeel
aboutalcoholanddruguse.
• Consideraplantomakesureyourchildor
hisfriendscannotgetalcoholorprescription
drugsinyourhome.
• Talkaboutrelationships,sex,andvalues.
• Encourageyourchildnottohavesex.
• Ifyouareuncomfortabletalkingabout
pubertyorsexualpressureswithyourchild,
pleaseaskmeorothersyoutrustforreliable
informationthatcanhelpyou.
• Useclearandconsistentrulesanddiscipline
withyourchild.
• Bearolemodelforhealthybehaviorchoices.
Feeling Happy
• Encourageyourchildtothinkthrough
problemsherselfwithyoursupport.
• Helpyourchildgureouthealthywaysto
dealwithstress.
• Spendtimewithyourchild.
• Knowyourchild’sfriendsandtheirparents,
whereyourchildis,andwhatheisdoingat
alltimes.
• Showyourchildhowtousetalktoshare
feelingsandhandledisputes.
• Ifyouareconcernedthatyourchildissad,
depressed,nervous,irritable,hopeless,or
angry,talkwithme.
School and Friends
• Checkinwithyourchild’steacherabouther
gradesontestsandattendback-to-school
eventsandparent-teacherconferencesif
possible.
• Talkwithyourchildasshetakesover
responsibilityforschoolwork.
• Helpyourchildwithorganizingtime,ifhe
needsit.
• Encouragereading.
• Helpyourchildndactivitiessheisreally
interestedin,besidesschoolwork.
• Helpyourchildndandtryactivitiesthat
helpothers.
• Giveyourchildthechancetomakemoreof
hisowndecisionsashegrowsolder.
Violence and Injuries
• Makesureeveryonealwayswearsaseatbelt
inthecar.
• DonotallowyourchildtorideATVs.
• Makesureyourchildknowshowtogethelp
ifheisfeelingunsafe.
• Removegunsfromyourhome.Ifyoumust
keepaguninyourhome,makesureitis
unloadedandlockedwithammunitionlocked
inaseparateplace.
• Helpyourchildgureoutnonviolentwaysto
handleangerorfear.
SOCIAL AND ACADEMIC COMPETENCE
VIOLENCE AND INJURY PREVENTION
RISK REDUCTION
EMOTIONAL WELL-BEING
PHYSICAL GROWTH AND 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. 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
Early Adolescent Visits
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Bright Futures Previsit Questionnaire Early Adolescent Visits

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