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Complete Packet- 15 months

15 month Developmental

Please read each questions carefully and check the box that best describes your child's behavior. Check the box if this behavior is a concern for you.

If other please explain below
If other please explain below:

Bright Futures- How is your child doing?

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.

We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.

Questions about your child

Lead Risk Assessment

Any child ages less than 72 months with a positive response to any of the following questions is at risk and must receive a blood lead test immediately

TB Risk Assessment

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.

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