Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 12 Month Visit

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.

Child's Full name * Child's Date of Birth * Do you have an appointment scheduled?

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 Establishing Routines Feeding Your Child Finding a Dentist Safety

Questions About Your Child

Have any of your child's relatives developed new medical problems since your last visit? If yes, please describe: Do you have concerns about how your child hears? Do you have any concerns about how your child speaks? Do you have concerns about how your child sees? Does your child hold objects close when trying to focus? Do your child's eyes appear unusual or seem to cross, drift, or be lazy? Do your child's eyelids droop or does one eyelid tend to close? Have your child's eyes ever been injured? Is your child infected with HIV? Do you know a dentist to whom you can bring your child? Does your child's primary water source contain fluoride? Does your child have any special health care needs? If yes, please describe: Have there been any major changes in your family lately? Any other changes? Does your child live with anyone who uses tobacco or spend time in any place where people smoke?

Your Growing and Developing Child

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

Lead Risk Assessment

Have siblings or playmates with lead poisoning? Live in or regularly visit a house or day care built before 1950? Mouth or eat non-food items (pica)?8 Reside in or visit a house built before 1978 with chipping paint or remodeling within the last 6 months? Play in bare soil or reside in a lead smelting area? Reside with an individual that works with or has hobbies using lead? Between 12 & 72 months, and has never received a blood lead test? Receive unusual medicines or folk remedies? Live in an area of the state at high-risk for lead poisoning? (list published annually)

TB Risk Assessmet

1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray? If yes, describe symptoms: 2. In the last year, has the child lived with or spent time with someone who has been sick with TB? 3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East? If yes, what country: 4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month? If yes, what country 5. Have any member of the child's household come to the United States from another country? If yes, what country: 6. Is the child exposed to a person who: 7. Is the child/teen in jail or ever been in jail? 8. does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression? If yes, name of disease or medication:

If yes, to any of the above, the child has and increased risk of TB infection and should have a TST/IGRA. All children with a positive TST/IGRA result must have a medical evaluation, including a chest X-ray. Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of active TB. If testing was done, please attach or enter results on next page.