Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 7 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.

School Your Growing Child 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

Vision

Do you have concerns about how your child sees? Has your child ever failed a school vision screening test? Does your child tend to squint?

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?

Hearing

Do you have concerns about how your child speaks? Do you have concerns about how your child hears? Does your child have trouble hearing with a noisy background or over the telephone? Does your child have trouble following the conversation when 2 or more people are talking at the same time? 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

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? If yes, name of symptoms: 2. In the last 2 years, has the child lived with or spent time with someone who has been sick with TB? z3. 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? 5. Have any member of the child's household come to the United States from another country? If yes, name of 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: