Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire 2 Month Visit

For us to provide you and your baby 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 appt? *

I have an appointment on the schedule

I need Ideal to contact me to schedule my child's 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.

How You Are Feeling

Getting back to normal activities

Feeling Sad

Your partner helping you take care of home and baby

Help taking care of your baby

Siblings getting along with baby

Taking time for yourself

Finding time alone with partner

Your Growing Baby

How you are doing with your baby

Where your baby sleeps

How your baby sleeps

How to keep your baby safe while sleeping

Tummy time

Rolling over

Talking with your baby

Calming your baby

Daily Ruitines

Your Baby & Family

Leaving your baby when going to work or school

Finding good child care

Feeding Your Baby

Feeding routine

When to begin solid food

Holidng

Burping

Your child's weight

Knowing when baby is hungry or full

Help with breastfeeding

Forumula Feeding

Safety

Car safety seats

How to check hot water temps

Chocking

Preventing falls from rolling over

Bathtub Safety

Cigarette Smoke

Questions About Your Baby

Have any of your baby's relatives developed new medical problems since your last visit?

Yes

Unsure

Vision - Do you have concerns about how your child sees?

Yes

Unsure

Do you have specific concerns about your baby's development, learning, or behavior?

Yes

If yes, describe:

Check off each of the tasks that your baby is able to do

Smiles

Coos

Looks at you

Comforts self

Has different types of cries to show when hungry or tired

Fusses if bored

Moves both arms and legs together

Holds head up when held

Pushes head up when lying on tummy

Today's date

Illini Pediatrics LLC, DBA Ideal Pediatrics

Available Forms

Complete Packet- 2 month

Bright Futures Previsit Questionnaire 2 Month Visit

What would you like to talk about today?

Questions About Your Baby