Whole Child Pediatrics

Bright Futures Previsit Questionnaire 1 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 name and date of birth *

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 Your Baby and Family Getting to Know Your Baby Feeding Your Baby Safety

Questions About Your Baby

Have any of your baby's relatives developed new medical problems since your last visit? Vision - Do you have concerns about how your child sees?

Tuberculosis

Has a family member or contact had tuberculosis or a positive tuberculin skin test? Was your child born in a country at high risk for tuberculosis (countries other than the United States, Canada, Australia, New Zealand, and Western Europe)? Has your child traveled (had contact with resident populations) for longer than 1 week to a country at high risk for tuberculosis? 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 Does your child live with anyone who uses tobacco or spend time in any place where people smoke?

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