Whole Child Pediatrics

Bright Futures Previsit Questionnaire 10 Year Visit

For us to provide your child 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: * Childs Date of Birth Does child have a scheduled 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.

School Your Growing Child Staying Healthy Healthy Teeth Safety

Questions About Your Child

Have any of your child?s relatives developed new medical problems since your last visit? If yes, please describe: If Yes, Describe

Tuberculosis

Was your child born in a country at high risk for tuberculosis (countries other than the United States, Canada, Australia, New Zealand, or Western Europe)? Has your child traveled (had contact with resident populations) for longer than 1 week to a country at high risk for tuberculosis? Has a family member or contact had tuberculosis or a positive tuberculin skin test? Is your child infected with HIV?

Dyslipidemia

Does your child have parents or grandparents who have had a stroke or heart problem before age 55? Does your child have a parent with elevated blood cholesterol (240 mg/dL or higher) or who is taking cholesterol medication?

Anemia

Does your child eat a strict vegetarian diet? If your child is a vegetarian, does your child take an iron supplement? Does your child?s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? Does your child have any special health care needs? If Yes, Describe Have there been any major changes in your family lately? Does your child live with anyone who uses tobacco or spend time in any place where people smoke?

Your Growing and Developing Child

Do you have specific concerns about your child?s development, learning, or behavior? If Yes, Describe Check off each of the following that are true for your child Describe Activity Done Well

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? Field37 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?