Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 11-14 Year Visits

For us to provide you with the best possible health care, we would like to get to know you better and know how things are going for your child.

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? What changes or challenges have there been at home since your last visit? Do you live with anyone who uses tobacco or spend time in any place where people smoke? If Yes, Describe

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

Their Growing and Changing Body School and Friends How They Are Feeling Healthy Behavior Choices Violence and Injuries

Questions

Dyslipidemia

Do they smoke cigarettes?

Anemia

Does their diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? Have they ever been diagnosed with iron deficiency anemia?

Alcohol or Drug Use

Have they ever had an alcoholic drink? Have they ever used marijuana or any other drug to get high?

For Females Only

Anemia

Do she have excessive menstrual bleeding or other blood loss? Does her period last more than 5 days?

Growing and Developing

Check off all the items that you feel are true for you Describe

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? 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