Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 1 Month Visit

For us to provide you and your baby with the best possible health care, we would like to know how things are going. Please answer all of the questions. Thank you.

Child's FULL name * Child's Date of Birth Do you have an appt? *

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.

How You Are Feeling Your Baby and Family Getting to Know Your Baby Feeding Your Baby Safety

Questions About Your Baby

Have any of your baby's relatives developed new medical problems since your last visit? Vision - Do you have concerns about how your child sees?

Tuberculosis

Has a family member or contact had tuberculosis or a positive tuberculin skin test? Was your child born in a country at high risk for tuberculosis (countries other than the United States, Canada, Australia, New Zealand, and Western Europe)? Has your child traveled (had contact with resident populations) for longer than 1 week to a country at high risk for tuberculosis? Does your child have any special health care needs? If yes, describe: Other than your baby's birth, have there been any major changes in your family lately? Any other changes?

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless Does your child live with anyone who uses tobacco or spend time in any place where people smoke?

Your Growing and Developing Baby

Do you have specific concerns about your baby's development, learning, or behavior? If yes, describe: Check off each of the tasks that your baby is able to do

Questions pertaining to birth mother

Edinburgh Post-Natal Depression As you have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt in the PAST SEVEN DAYS. Not just how you feel today.

Mother's Name I have felt happy:

In the past 7 days:

1. I have been able to laugh and see the funny side of things 2. I have looked forward with enjoyment to things 3. I have blamed myself unnecessarily when things went wrong 4. I have been anxious or worried for no good reason 5. I have felt scared or panicky for no very good reason 6. Things have been getting on top of me 7. I have been so unhappy that I have had difficulty sleeping 8. I have felt sad or miserable 9. I have been so unhappy that I have been crying 10. The thought of harming myself has occurred to me Today's date