Bright Futures Previsit Questionnaire

7 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.
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 your child is learning and doing in school ❑ Bullying ❑ After-school activities and care
School
❑ Special education needs ❑ How your child acts ❑ Talking with your child’s school
❑ How your child feels about herself ❑ Following rules ❑ Getting ready for puberty ❑ Being angry
Your Growing Child
❑ Your child dealing with his problems ❑ Becoming more independent
❑ Your child’s weight
✔ ❑ 1 hour of physical activity daily ❑ Playing sports ❑ TV time ❑ Getting enough calcium
Staying Healthy
❑ Drinking enough water ✔ ❑ How much your child should eat at one time
Healthy Teeth ❑ Regular dentist visits ❑ Brushing teeth twice daily ❑ Flossing daily
❑ Booster seats ❑ Helmets and sports safety ❑ Swimming safety ❑ Wearing sunscreen
Safety ❑ Knowing your child’s computer use ❑ Knowing your child’s friends and their families ❑ Gun safety
❑ Smoke-free house and cars ❑ Preventing sexual abuse
Questions About Your Child
Have any of your child’s relatives developed new medical problems since your last visit? If yes, please describe: ✔
❑ Yes ❑ No ❑ Unsure

Do you have concerns about how your child sees? ❑ Yes ✔

❑ No ❑ Unsure
Vision Has your child ever failed a school vision screening test? ❑ Yes ✔
❑ No ❑ Unsure
Does your child tend to squint? ❑ Yes ❑ No
✔ ❑ Unsure
Do you have concerns about how your child speaks? ❑ Yes ✔
❑ No ❑ Unsure
Do you have concerns about how your child hears? ❑ Yes ❑ No
✔ ❑ Unsure
Hearing
Does your child have trouble hearing with a noisy background or over the telephone? ❑ Yes ❑ No
✔ ❑ Unsure
Does your child have trouble following the conversation when 2 or more people are talking at the same time? ❑ Yes ❑ No
✔ ❑ Unsure
Was your child born in a country at high risk for tuberculosis (countries other than the United States,
❑ Yes ❑ No
✔ ❑ Unsure
Canada, Australia, New Zealand, or Western Europe)?
Has your child traveled (had contact with resident populations) for longer than 1 week to a country
Tuberculosis ❑ Yes ❑ No
✔ ❑ Unsure
at high risk for tuberculosis?
Has a family member or contact had tuberculosis or a positive tuberculin skin test? ❑ Yes ❑ No
✔ ❑ Unsure
Is your child infected with HIV? ❑ Yes ✔
❑ No ❑ Unsure
Does your child eat a strict vegetarian diet? ❑ Yes ❑ No
✔ ❑ Unsure
Anemia If your child is a vegetarian, does your child take an iron supplement? ❑ No
✔ ❑ Yes ❑ Unsure
Does your child’s diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? ❑ No
✔ ❑ Yes ❑ Unsure
Does your child have any special health care needs? ✔
❑ No ❑ Yes, describe:

Have there been any major changes in your family lately? ❑ Move ❑ Job change ❑ Separation ❑ Divorce ❑ Death in the family ❑ Any other changes?

Does your child live with anyone who uses tobacco or spend time in any place where people smoke? ✔
❑ No ❑ Yes
Your Growing and Developing Child
Do you have specific concerns about your child’s development, learning, or behavior? ✔
❑ No ❑ Yes, describe:

Check off each of the following that are true for your child.
❑ Eats healthy meals and snacks ✔❑ Is doing well in school ✔
❑ Is vigorously active for 1 hour a day
✔❑ Has friends ❑ Participates in an after-school activity ❑ Does chores when asked
✔
✔❑ Gets along with family

The recommendations in this publication do not indicate an

exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.

PAGE 1 OF 1
 ACCOMPANIED BY/INFORMANT PREFERRED LANGUAGE DATE/TIME Name

DRUG ALLERGIES CURRENT MEDICATIONS ID NUMBER

WEIGHT (%) HEIGHT (%) BMI (%) BLOOD PRESSURE BIRTH DATE AGE

See growth chart.

M ✓F
History Physical Examination
Previsit Questionnaire reviewed Child has special health care needs = NL
Bright Futures Priority Additional Systems
Child has a dental home
■ MUSCULOSKELETAL (hip, knee, ankle) ■GENERAL ■HEART
Concerns and questions None Addressed (see other side) ■ MOUTH/TEETH (caries, gingival) APPEARANCE ■ABDOMEN
■ BREASTS/GENITALIA ■NECK ■BACK
SEXUAL MATURITY RATING ■HEAD ■SKIN
■EYES ■NEUROLOGIC
■EARS
Follow-up on previous concerns None Addressed (see other side)
■NOSE
■LUNGS
■THROAT
Abnormal findings and comments

Interval history None Addressed (see other side)

Medication Record reviewed and updated

Social/Family History Assessment

See Initial History Questionnaire. No interval change Well child
Family situation
After-school care: Yes ■ No
Changes since last visit

Anticipatory Guidance
Discussed and/or handout given
Review of Systems
■SCHOOL
Show interest in school
■ACTIVITY
NUTRITION AND PHYSICAL SAFETY
Know child’s friends
See Initial History Questionnaire and Problem List.
Communicate with teachers Encourage proper nutrition Home emergency plan
No interval change
■MENTAL
DEVELOPMENT AND
HEALTH
Eat meals as a family
60 minutes of physical
Safety rules with adults
Appropriate vehicle
Changes since last visit
Encourage independence activity daily restraint
Praise strengths Limit TV and screen time Helmets and pads
Nutrition Be a positive role model ORAL HEALTH Supervise around water
Discuss expected body Dental visits twice a year Smoke-free environment
Sleep: ■ NL changes Brush teeth twice a day Guns
Physical activity Floss teeth daily Monitor computer use
Wear mouth guard during
Play time (60 min/d) Yes No sports
Screen time (<2 h/d) ■ Yes No
School: Grade Special education Yes ■ No Plan
Social interaction ■ NL Immunizations (See Vaccine Administration Record.)
Performance ■ NL Laboratory/Screening results: Vision Hearing
Behavior ■ NL
Attention ■ NL Referral to
Homework ■ NL
Parent/Teacher concerns None Follow-up/Next visit
Home: Cooperation ■ NL
Parent-child interaction ■ NL See other side
Sibling interaction ■ NL
Oppositional behavior ■ None Print Name Signature
PROVIDER 1
Development (if not reviewed in Previsit Questionnaire)
Eats healthy meals and snacks Is doing well in school
Participates in an after-school activity Does chores when asked
Has friends Gets along with family
Is vigorously active for 1 hour a day PROVIDER 2

HE0496 WELL CHILD/7 to 8 years

 This American Academy of Pediatrics Visit Documentation Form is consistent with
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as
a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Copyright © 2010 American Academy of Pediatrics. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

HE0496 9-234/0109
 Bright Futures Patient Handout
7 and 8 Year Visits
Doing Well at School Eating Well, Being Active Handling Feelings

DEVELOPMENT AND MENTAL HEALTH

SCHOOL

NUTRITION AND PHYSICAL ACTIVITY

Playing It Safe

Healthy Teeth
ORAL HEALTH
SAFETY

The recommendations in this publication do not indicate an

exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.

PAGE 1 OF 1
 Bright Futures Parent Handout
7 and 8 Year Visits
Here are some suggestions from Bright Futures experts that may be of value to your family.

Staying Healthy School

NUTRITION AND PHYSICAL ACTIVITY

SCHOOL
SAFETY

Healthy Teeth

ORAL HEALTH
Safety Your Growing Child
DEVELOPMENT AND MENTAL HEALTH
SAFETY

The recommendations in this publication do not indicate an

exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances,
may be appropriate. Original document included as part of
Bright Futures Tool and Resource Kit. Copyright © 2010
American Academy of Pediatrics. All Rights Reserved. The
American Academy of Pediatrics does not review or endorse
any modifications made to this document and in no event shall
the AAP be liable for any such changes.

PAGE 1 OF 1