Illini Pediatrics LLC, DBA Ideal Pediatrics

Bright Futures Previsit Questionnaire (First week)

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? *

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 Used to Your Baby Feeding Your Baby Safety Baby Care

Questions About Your Baby

Have any of your baby's relatives developed new medical problems recentlyt? Vision - Do you have concerns about how your child sees? Does your child have any special health care needs? If yes, describe: Other than your baby's birth, have there been any major changes in your family lately? Any other changes?

Over the past 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless

Your Growing and Developing Baby

Do you have specific concerns about your baby's development, learning, or behavior? If yes, describe: Check off each of the tasks that your baby is able to do Today's date