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Bright Future Pre Visit Questionnaire
To provide you and your child with the best possible health care, we would like to know how things are going.Please answer all the questions. Thank you!
Date
-
Month
-
Day
Year
Date
Patient's Age
*
Please Select
3 Years Old
4 Years Old
5 Years Old
6 Years Old
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11-14 Years Old
Patients Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
What would you like to talk about today? Do you have any concerns, questions, or problems that you would like to discuss today? (If yes, describe)
What excites or delights you most about your child?
Does your child have special health care needs? (If Yes, describe)
Have there been major changes lately in your child's or family's life? (If Yes, describe)
Have any of your child's relatives developed new medical problems since your last visit? (If yes, or unsure, please describe)
Does your child live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?
YES
NO
UNSURE
Do you have specific concerns about your child’s development, learning, or behavior? (If yes, or unsure, please describe)
Check off each of the task that your child is able to do.
Go to the bathroom and urinate by herself
Put on a Coat, Jacket, or Shirt by himself
Eat by herself
Begin to play make-believe
Play and share with others
Use 3-word sentences
Speak so strangers can understand 75% of what he says
Tell you a story from a book or TV
Compare things using words such as bigger and shorter
Understand simple prepositions, Such as on or under
Pedal a tricycle
Climb on and off a couch or chair
Jump Forward
Draw a single circle
Draw a person with head and one other body part
Cut with child scissors
Check off each of the task that your child is able to do.
Go to the bathroom and have a bowel movement by herself.
Dress and undress without much help.
Play Make-believe.
Answer questions such as "What do you do when you are cold?" and "When you are sleepy?"
Use 4-word sentances.
Speak so strangers can understand 100% of what she says.
Draw pictures you recognize.
Follow simple rules when playing board or card games.
Tell you a story from a book.
Skip on one foot.
Climb stairs, using one foot, then the other, without support.
Draw a person with at least 3 body parts.
Draw a simple cross.
Unbutton and button medium-sized buttons.
Grasp a pencil with a thumb and finger instead of her fist.
Check off each of the task that your child is able to do.
Is beginning to skip.
Walk on tiptoes when asked.
Catch a bounced ball with 2 hands.
Copy a triangle.
Draw a 6-part person.
Copy first name.
Cut well with scissors.
Spread with a knife.
Dress and undress without help.
Urinate and have a bowel movement on her own.
Is dry through the day.
Tell a story of 2 sentences or more.
Follow directions for 4 individual prepositions, such as on, under, behind, and in front of.
Play and interact with peers.
Answer “why” questions.
Count 5 objects.
Name 3 or more single numbers.
Name 4 or more letters out of alphabetic order.
Write 2 or more letters.
Check off each of the task that your child is able to do.
Ride a standard bike.
Hop on one foot 3 to 4 times.
Catch a small ball with 2 hands.
Draw a 12-part person.
Write first and last names in uppercase or lowercase letters.
Cut most foods with a knife.
Tie shoes.
Is dry day and night.
Tell a story with a beginning, a middle, and an end.
Choose preferred foods at breakfast and lunch.
Start and continue conversations with peers.
Master all consonant sounds and combinations, such as "d" or "ch."
Play and interact with at least one "best friend."
Print 3 or more simple words without copying.
Count 10 objects.
Do simple addition and subtraction with objects.
Check off each of the task that your child is able to do.
Shows the ability to get along with others and control his emotions
Chooses to eat healthy foods and participate in physical activity every day
Forms caring, supportive relationships with family members, other adults, and peers
Check off each of the task that your child is able to do.
My child does things that help her have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping herself safe.
My child has at least one adult in his life who cares about him and knows he can go to if he needs help.
My child has at least one friend or a group of friends who she feels comfortable around.
My child helps others by himself or by working with a group in school, a faith-based organization, or the community.
My child is able to bounce back when things don’t go her way.
My child feels hopeful and self-confident.
My child is becoming more independent and making more decisions on his own as he gets older
Risk Assessment
Anemia
Rows
Yes
No
Unsure
Does your child’s diet include iron-rich foods, such as meat, iron-fortified cereals, or beans?
Do you ever struggle to put food on the table?
Anemia
Rows
Yes
No
Unsure
Does your child’s diet include iron-rich foods, such as meat, iron-fortified cereals, or beans?
Does your child eat a vegetarian diet (does not eat red meat, chicken, fish, or seafood)?
If your child is a vegetarian (does not eat red meat, chicken, fish, or seafood), does your child take an iron supplement?
Do you ever struggle to put food on the table?
Anemia
Rows
Yes
No
Unsure
Does your child’s diet include iron-rich foods, such as meat, iron-fortified cereals, or beans?
Has your child ever been diagnosed with iron deficiency anemia?
Does your family ever struggle to put food on the table?
If your child is female, does she have excessive menstrual bleeding or other blood loss?
If your child is female, does her period last more than 5 days?
Dyslipidemia
Rows
Yes
No
Unsure
Does your child have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (male) or 65 (female)?
Does your child have a parent with an elevated blood cholesterol level (240 mg/dL or higher) or who is taking cholesterol medication?
Hearing
Rows
Yes
No
Unsure
Do you have concerns about how your child hears?
Do you have concerns about how your child speaks?
Hearing
Rows
Yes
No
Unsure
Do you have concerns about how your child hears?
Lead
Rows
Yes
No
Unsure
Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months?
Oral Health
Rows
Yes
No
Unsure
Does your child have a dentist?
Does your child’s primary water source contain fluoride?
Oral Health
Rows
Yes
No
Unsure
Does your child’s primary water source contain fluoride?
Sexually Transmitted Infections/HIV
Rows
Yes
No
Unsure
Adolescents who are sexually active are at risk of sexually transmitted infection, including HIV. Adolescents who use injection drugs are at risk of HIV. Are you concerned that your young adolescent might be at risk?
Tuberculosis
Rows
Yes
No
Unsure
Was your child or any household member born in, or has he or she traveled to, a country where tuberculosis is common (this includes countries in Africa, Asia, Latin America, and Eastern Europe)?
Has your child had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
Is your child infected with HIV?
Vision
Rows
Yes
No
Unsure
Do you have concerns about how your child sees?
Has your child ever failed a school vision screening test?
Does your child tend to squint?
Vision
Rows
Yes
No
Unsure
Do you have concerns about how your child sees?
Does your child have trouble with near or far vision?
Has your child ever failed a school vision screening test?
Does your child tend to squint?
Anticipatory Guidance: How are things going for you, your child, and your family?
Living Situation and Food Security
Rows
Yes
No
Do you have enough heat, hot water, electricity, and working appliances?
Do you have problems with bugs, rodents, peeling paint or plaster, mold, or dampness?
Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?
Within the past 12 months, did the food you bought not last, and you did not have money to get more?
Neighborhood and Family Violence (Bullying and Fighting)
Rows
Yes
No
Are there frequent reports of violence in your community or school?
Has your child ever been bullied or hurt physically by someone?
Has your child ever bullied or been aggressive with others?
Neighborhood and Family Violence (Bullying and Fighting)
Rows
Yes
No
Are there frequent reports of violence in your community or school?
Has your child ever been bullied or hurt physically by someone?
Has your child ever bullied or been aggressive with others?
Have you talked with your child about how to get help and who to call if there is an emergency?
Has your child ever told you she was touched in a way that made her uncomfortable or on her private parts?
Neighborhood and Family Violence (Bullying and Fighting)
Rows
Yes
No
Are there frequent reports of violence in your community or school?
Has your child ever been bullied or hurt physically by someone?
Has your child ever bullied or been aggressive with others?
Has your child felt excluded or not a part of any group of friends?
Has your child ever told you she was touched in a way that made her uncomfortable or on her private parts?
Interpersonal Violence (Fighting and Bullying)
Rows
Yes
Sometimes
No
Are there frequent reports of violence in your community or school?
Is your child involved in any of the violence?
Do you think your child is safe in the neighborhood?
Has your child ever been injured in a fight?
Has your child been bullied or hurt by others?
Has your child bullied or been aggressive toward others?
Have you talked with your child about violence in dating situations and how to be safe?
Living Situation and Food Security
Rows
Yes
No
Is permanent housing a worry for you?
Do you have enough heat, hot water, electricity, and working appliances?
Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?
Within the past 12 months, did the food you bought not last, and you did not have money to get more?
Living Situation and Food Security
Rows
Yes
Sometimes
No
Do you have concerns about your living situation?
Do you have enough heat, hot water, and electricity?
Do you have appliances that work?
Do you have problems with bugs, rodents, or peeling paint or plaster?
In the past 12 months, did you worry that your food would run out before you got money to buy more?
In the past 12 months, did the food you bought not last, and you did not have money to buy more?
Food Security
Rows
Yes
No
Within the past 12 months, were you ever worried whether your food would run out before you got money to buy more?
Within the past 12 months, did the food you bought not last, and you did not have money to get more?
Alcohol and Drugs
Rows
Yes
No
Does anyone in your household drink beer, wine, or liquor?
Do you or other family members use marijuana, cocaine, pain pills, narcotics, or other controlled substances?
Alcohol and Drugs
Rows
Yes
No
Is there anyone in your child’s life whose alcohol or drug use concerns you?
Tobacco, E-cigarettes, Alcohol, and Drugs
Rows
Yes
No
Is there anyone in your child’s life whose alcohol or drug use concerns you?
Do any of your child’s friends smoke, use or vape e-cigarettes, drink alcohol or beer, or use drugs?
Harm From the Internet
Rows
Yes
No
Do you supervise your child’s Internet use?
Do you have rules about Internet use?
Do you use safety filters on computers, tablets, and smartphones?
Positive Family Interactions
Rows
Yes
No
Are your family members loving and affectionate with one another?
Do you praise your child when he is being good?
Do you have ways to constructively handle anger and settle disputes in your family?
Does everyone who cares for your child set the same limits for your child?
Do you allow your child to make choices, such as what clothes to wear or what books to read?
Do you use simple words when asking your child a question or telling her what to do?
Emotional Security and Self-Esteem
Rows
Yes
No
Does your child usually seem happy?
Are there things your child is really good at doing or is proud of?
Emotional Security and Self-Esteem
Rows
Yes
No
Does your child usually seem happy?
Are there things your child is really good at doing or is proud of?
Does your child have the chance to help others at home, at school, or in your community?
Connectedness With Family
Rows
Yes
No
Does your family get along well with each other?
Does your family do things together?
Connectedness With Family and Peers
Rows
Yes
No
Does your family get along well with each other?
Does your family do things together?
Does your child have chores or responsibilities at home?
Does your child have friends at school or in your neighborhood?
Connectedness With Family and Peers
Rows
Yes
Sometimes
No
Does your family get along well with each other?
Do you take time to talk with your child every day?
Does your family do things together?
Does your child have chores or responsibilities at home?
Do you have clear rules and expectations for your child?
Do you let your child know when he does something good?
Connectedness With Community
Rows
Yes
Sometimes
No
Does your child have interests outside of school?
Does your child help others at home, in school, or in your community?
Family Rules and Routines
Rows
Yes
No
Does your child have chores or responsibilities at home?
Do you have clear rules and expectations for your child?
When your child breaks the rules, are you consistent with consequences and discipline?
Do you let your child know when she is being good?
Does your child have problems dealing with angry feelings?
Do you help your child control his anger?
Your Child's Development
Rows
Yes
No
Does your child have chores or responsibilities at home?
Do you have clear rules and expectations for your child?
When your child breaks the rules, are you consistent with consequences and discipline?
Do you let your child know when he is doing a good job?
Does your child frequently have worries?
Does your child have problems dealing with anger or frustration?
Do you help your child control her anger, deal with worries, and solve problems?
School
Rows
Yes
No
Did your child attend a preschool program?
Has your child started elementary school?
Do you have any concerns about your child’s school experience?
Are you able to attend activities or functions at your child’s school?
Is your child involved in after-school activities?
Does your child receive any special education services?
Temper Problems, Setting Reasonable Limits, and Friends
Rows
Yes
No
Has your child experienced any recent stresses at home or in school?
Do you have clear rules and expectations for your child?
When your child breaks the rules, are you consistent with consequences and discipline?
Do you help your child control his anger, deal with worries, and solve problems?
Have you and your child talked about how to say no to smoking, alcohol, and drug use?
Puberty and Pubertal Development
Rows
Yes
No
Have you talked with your child about how his body will change during puberty?
Onset of Puberty and Sexual Safety
Rows
Yes
No
Have you talked with your child about the body changes that occur during puberty?
Have you discussed privacy and body safety with your child?
Have you and your child talked about sex?
Does your child know to tell a trusted adult if someone touches her private parts or if someone encourages her to do other things that make her uncomfortable or she knows are wrong?
School
Rows
Yes
No
Is your child doing well in school?
Has your child missed more than 2 days of school in any month?
Does your child have any difficulties at school or get extra help?
Does your child like school?
Does your child have friends at school?
Is your child involved in after-school activities?
School
Rows
Yes
No
Do you have concerns about your child’s school experience?
Has your child missed more than 2 days of school in any month?
Does your child have any difficulties at school or get extra help in any subjects?
Does your child participate in activities outside of school?
School Performance
Rows
Yes
Sometimes
No
Is your child getting to school on time?
Is your child having any problems at school?
Does your child complete homework on time?
Has your child missed more than 2 days of school in any month?
Taking Care of Yourself
Rows
Yes
No
Do you take time for yourself?
Do you feel you are able to balance family and work?
Do you spend time alone with your partner?
Intimate Partner Violence
Rows
Yes
No
Do you always feel safe in your home?
Has your partner, or another significant persion in your life, ever hit, kicked, or shoved you, or physically hurt your or your child?
Playing with siblings and Peers
Rows
Yes
No
Does your child engage in fantasy play with dolls, toy animals, or blocks?
Do you spend time alone with your child doing things you both enjoy?
Does your child have chances to play with other children (such as on playdates and at preschool)?
When your child plays with other children, do you help him learn how to take turns?
If you have other children, do they get along with each other?
Are you expecting or thinking about having another child?
Safety in the Community
Rows
Yes
No
Do you feel safe in your community?
Do you have someone you can turn to if you are concerned about your child's safety?
Do you have connections to your community through faith groups, volunteer organizations, or recreational programs?
Do you spend time with parents of other children in your commuinity?
Reading and talking with your child
Rows
Yes
No
Do you read, sing songs, or play word games with your child every day?
When you are reading together, do you ask your child questions about the pictures or story in the book?
Do you encourage your child to tell you about his day?
Does your family speak more than one language at home?
Coping With Stress and Decision-making
Rows
Yes
Sometimes
No
Does your child worry too much or appear overly anxious?
Have you discussed ways to deal with stress?
Do you help your child make decisions and solve problems?
Getting Ready for School
Language Understanding and Fluency
Rows
Yes
No
Does your child clearly communicate his wants and needs to others?
Do you respond to your child's questions with short and simple answers?
Do you give your child plenty of time to tell a story or answer a question?
Do you talk, sing, and read together every day?
Feelings
Rows
Yes
No
Is your child generally happy and active?
Do you help your child say, "I'm sorry", for hurting others' feelings?
Opportunities to Socialize With Other Children
Rows
Yes
No
Is your child interested in other children?
Do your child have a chance to play with othe children in playgroups or at preschool?
Does your child have a best friend?
Do you praise your child when she is good or has finished a task?
Early Childhood Programs and Preschool
Rows
Yes
No
Does your child attend preschool?
Are you happy with your child care or preschool arrangement?
Do you visit your child's preschool and participate in activities there?
Readiness for School
Rows
Yes
No
Do you have any concerns about your child starting school in the coming year?
Are you doing things to get your child ready for preschool? This could include reading together and going to the library, the park, the zoo, and other places.
Eating Healthy And Being Active
Healthy Teeth
Rows
Yes
No
Does your child brush his teeth twice a day?
Does your child see the dentist twice a year?
Healthy Teeth
Rows
Yes
No
Does your child brush his teeth twice a day?
Does your child see the dentist twice a year?
Does your child use a mouth guard if playing contact sports?
Healthy Teeth
Rows
Yes
No
Does your child brush his teeth twice a day?
Does your child see the dentist twice a year?
Does your child use a mouth guard if playing contact sports?
Does your child regularly drink soda, juice, or other sugar-sweetened drinks?
Healthy Teeth
Rows
Yes
Sometimes
No
Does your child see the dentist regularly?
Do you have trouble getting dental care?
Body Image
Rows
Yes
Sometimes
No
Do you have any concerns about your child’s nutrition, weight, or physical activity?
Does your child talk about getting fat or dieting to lose weight?
Nutritious Foods
Rows
Yes
No
Does your child drink water every day?
Do you offer your child a variety of foods, including vegetables, fruits, and foods rich in protein, such as meat, eggs, chicken, or fish?
Is your child willing to try new flavors and food textures?
Do you let your child decide how much to eat and when to stop?
Nutrition
Rows
Yes
No
Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.
Does your child drink soda, juice, or other sugar-sweetened drinks?
Does your child eat breakfast every day?
Nutrition
Rows
Yes
No
Do you have any concerns about your child’s weight or eating habits?
Do you have any concerns about your child’s eating? This includes drinking enough milk and eating vegetables and fruits.
Does your child drink or eat 3 servings of dairy foods, such as milk, cheese, or yogurt, a day?
Do you eat meals together as a family?
Does your child drink soda, juice, or other sweetened drinks?
Does your child eat breakfast every day?
Nutrition
Rows
Yes
No
Do you have any concerns about your child’s weight?
Do you have any concerns about her eating? This includes drinking enough milk and eating vegetables and fruits.
Do you eat family meals together?
Do you hear your child talking about how he looks or dieting?
Healthy Eating
Rows
Yes
Sometimes
No
Do you think your child eats healthy foods?
Do you have any difficulty getting healthy food for your family?
Do you have any concerns about your child’s eating habits or nutrition?
Do you eat meals together as a family?
How many ounces of milk does your child drink on most days?
Daily Routines that Promote Health
Rows
Yes
No
Does your child sleep well?
Do you have a regular bedtime and mealtime routines?
Do you brush your child’s teeth twice a day with a pea-sized amount of fluoridated toothpaste?
Promoting Physical Activity and Limiting TV
Rows
Yes
No
Are you physically active together as a family, such as going on walks or playing in the park?
Does your child play actively for at least 1 hour a day?
Does your child have a TV or an Internet-connected device in her bedroom?
Has your family made a media use plan to help everyone balance time spent on media with other family and personal activities?
Physical Activity
Rows
Yes
No
Is your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.
Does your child have a TV or an Internet-connected device in his bedroom?
Has your family made a family media use plan to help everyone balance time spent on media with other family and personal activities?
Does your child have trouble going to sleep or does he wake up during the night?
Does your child have a regular bedtime?
Physical Activity
Rows
Yes
No
Is your child physically active at least 1 hour every day? This includes running, playing sports, or active play with friends.
Do you have any concerns about your child’s physical activity level, such as it being either too much or too little?
Does your child have trouble going to sleep or does she wake up during the night?
Does your child have a TV or an Internet-connected device in her bedroom?
Has your family made a family media use plan to help everyone balance time spent on media with other family and personal activities?
Physical Activity and Sleep
Rows
Yes
Sometimes
No
Is your child physically active at least 1 hour a day? This includes running, playing sports, or doing physically active things with friends.
Are there opportunities to safely play outside in your neighborhood?
Do you and your child participate in physical activities together?
Does your child have a TV, computer, tablet, or smartphone in his bedroom?
Do you have rules about screen time for your child?
Has your family made a family media use plan to help everyone balance time spent on media with other family and personal activities?
Does your child have a regular bedtime?
Limiting TV and Promoting Physical Activity
Rows
Yes
No
Does your child have a TV or an Internet-connected devicee in her bedroom?
Has your family made a media plan to help everyone balance time spent on media with other family and personal activities?
Does your child play actively for at least 1 hour a day?
Does your child play with other children?
Are you physically active together as a family, such as going for walks or playing in the park?
Does your child play actively for at least 1 hour a day?
How much time every day does your child spend watching TV or using computers, tablets, or smartphones?
How much time every day does your child spend watching TV or using computers, tablets, or smartphones (not counting schoolwork)?
Your Child's Emotional Well-being
Mood and Mental Health
Rows
No
Sometimes
Yes
Is your child frequently irritable?
Have you noticed any changes in your child’s weight or sleep habits?
Do you and your child often have conflicts about what your culture expects for her behavior and how her friends behave?
Do you have any concerns about your child’s emotional health, such as being frequently sad or depressed?
Sexuality
Rows
No
Sometimes
Yes
Have you and your child talked about how his body will change during puberty?
Do you have house rules about curfews, dating, and friends?
Sexual Activity
Rows
No
Yes
Have you and your child talked about sex?
Have you talked about ways to deal with any pressures to have sex?
Substance Use
Rows
No
Yes
Have you talked with your child about alcohol and drug use?
Do you know your child’s friends?
Do you know where your child is and what she does after school and on the weekends?
Do you have consequences for your child if you discover he is using tobacco, alcohol, or drugs?
To your knowledge, is your child currently using alcohol or drugs, or has she used them in the past?
Acoustic Trauma
Rows
No
Sometimes
Yes
Does your child often listen to loud music?
Safety
Car and Home Safety
Rows
Yes
No
Is your child buckled securely in a car safety seat in the back seat every time he rides in a vehicle?
Are you having any problems with your car seat?
Does everyone in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
Do you cut foods such as grapes and hot dogs into small pieces to prevent choking?
Does your child play in a driveway or close to the street?
Do you keep furniture away from windows and use operable window guards on windows on the second floor and higher? (Operable means that, in case of an emergency, an adult can open the window.)
Car and Home Safety
Rows
Yes
No
Is your child fastened securely in a car safety seat or belt-positioning booster seat in the back seat every time he rides in a vehicle?
Does everyone else in the vehicle always use a lap and shoulder seat belt, booster seat, or car safety seat?
Seat Belt and Helmet Use
Rows
No
Sometimes
Yes
Do you always wear a lap and shoulder seat belt and bicycle helmet?
Do you insist your child wears a lap and shoulder seat belt when in a car?
Do you insist that your child use a life jacket when he does water sports?
Safety During Physical Activity
Rows
Yes
No
Does your child always wear a helmet to protect his head when biking, skating, or doing other outdoor activities?
Outdoor Safety
Rows
Yes
No
Do you watch your child closely when she plays outside, especially near streets and driveways?
Are there swimming pools in your neighborhood?
Are you planning to have your child learn to swim?
Does your child always wear an US Coast Guard–approved life jacket when on a boat?
Does your child always use sunscreen when he plays outside?
Outdoor Safety
Rows
Yes
No
Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?
Does your child know street safety habits, such as stopping at the curb, looking both ways, and never crossing the street without a grown-up?
Does your child know how to swim?
Does your child know to always have an adult watching her in the water and never to swim alone?
Does your child always use sunscreen when playing outside?
Outdoor Safety
Rows
Yes
No
Does your child always wear a helmet to protect her head when biking, skating, or doing other outdoor activities?
Does your child know how to swim?
Does your child know to always have an adult watching her in the water and never to swim alone?
Does your child always use sunscreen when playing outside?
Outdoor Safety
Rows
Yes
No
Does your child know how to swim?
Does your child know to always have an adult watching her in the water and never to swim alone?
Does your child always use sunscreen when playing outside?
Sun Protection
Rows
No
Sometimes
Yes
Does your child use sunscreen?
Water Safety
Rows
Yes
No
Are there swimming pools near your home?
Do you always stay within arm’s reach of your child when he is in or near water?
Does your child always wear an US Coast Guard–approved life jacket when on a boat?
Home Fire Safety
Rows
Yes
No
Do you have working smoke alarms installed on every level of your home?
Do you have carbon monoxide detectors/alarms in your home?
Do you have an emergency escape plan in case of fire?
Does your child know what to do if the fire alarm rings?
Pets
Rows
Yes
No
Do you own a pet?
Have you taught your child how to behave around animals so she does not get bitten or scratched?
Knowing Your Child's Friends and Their Families
Rows
Yes
No
Do you know your child’s friends and their families?
Does your child know how to get help in an emergency if you are not there?
Gun Safety
Rows
Yes
No
Does anyone in your home or the homes where your child spends time have a gun?
If yes, is the gun unloaded and locked up?
If yes, is the ammunition stored and locked up separately from the gun?
Gun Safety
Rows
Yes
No
Does anyone in your home or the homes where your child spends time have a gun?
If yes, is the gun unloaded and locked up?
If yes, is the ammunition stored and locked up separately from the gun?
Have you talked to your child about gun safety?
Harm From Adults
Rows
Yes
No
Have you taught your child that it is never OK for an adult to tell a child to keep secrets from her parents?
Does your child know that it is never OK for an older child or an adult to ask to see his private parts?
Harm From Adults
Rows
Yes
No
Do you know your child’s friends and their families?
Does your child know how to get help in an emergency if you aren’t there?
Have you taught your child that is it never OK for an adult to tell a child to keep secrets from his parents?
Does your child know that it is never OK for an older child or an adult to ask to see her private parts?
Submit
Should be Empty: