Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 15 to 17 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 scheduled? *

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 have any special health care needs? If Yes, Describe Do your child live with anyone who uses tobacco or spend time in any place where people smoke? If Yes, Describe How many hours per day does your child watch TV, play video games, and use the computer (not for schoolwork)?

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

Check anything that your child may have mentioned, or you may have noticed they are struggling with.

Questions

Alcohol or Drug Use

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

STIs

Do they now use or have they ever used injectable drugs?

For Females Only

Anemia

Does 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 your child 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? If yes, name symptoms: 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? If yes, where 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: