Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 6 Year Visit

For us to provide 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? *

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.

Ready for School Your Child and Family Staying Healthy Healthy Teeth Safety

Questions About Your Child

Have any of your child?s relatives developed new medical problems since your last visit? If yes, please describe: If Yes, Describe

Anemia

Does your child eat a strict vegetarian diet? If your child is a vegetarian, does your child take an iron supplement? Does your child?s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans?

Oral Health

Does your child have a dentist? Does your child?s primary water source contain fluoride? Does your child have any special health care needs? If Yes, Describe Have there been any major changes in your family lately? 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 development, learning, or behavior? If Yes, Describe Check off each of the following that are true for your child

Lead Risk Screening

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

TB Screening

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? 2. In the last 2 years, 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, where: 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? 5. Have any member of the child's household come to the United States from another 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: