Visit Documentation Forms: 10 Year Visit

Well Child | 10 Year Visits

Name

ID number

Date of Birth

Age

Accompanied By

Preferred Language:

Date and Time

Weight (%)

Height (%)

BMI (%)

BP (%)

Vitals (if indicated)

Temp

Resp Rate

Spo₂

HISTORY

Concerns and Questions

Interval History:

Medical History

Child has special health care needs.

Areas reviewed and updated as needed

Past Medical History (See Initial History Questionnaire.)

Surgical History (See Initial History Questionnaire.)

Problem List (See Problem List.)

Medications

No known drug allergies

Reviewed and updated (See Medication Record.)

Allergies

Nutrition

Good appetite

Good variety

Daily fruits and vegetables

Iron

Calcium

Amount

Comments

Girls: Menarche:

Yes No

If yes, please describe

If no, please describe

Please specify if Other is selected

Elimination

Regular soft stools:

Sleep

Physical Activity

If no, please describe

Screen time

Source

School

Grade

Performance

Parent/teacher concerns

Behavior

Parent-child-sibling interaction

DEVELOPMENT

Normal development

See Previsit Questionnaire.

If yes, please describe

Shows the ability to get along with others and control emotions

Chooses to eat healthy foods and participate in physical activity every day

Forms caring, supportive relationships with family members, other adults, and peers

SOCIAL AND FAMILY HISTORY

Changes since last visit

No Interval Change

If yes, please describe

Observation of parent-child interaction

After-school care

REVIEW OF SYSTEMS

A 10-point review of systems was performed and results were negative except for any positive results listed below.

Required Field = Focus area for this Bright Futures Visit

Constitutional

Eyes

Head, Ears, Nose, and Throat

Cardiovascular

Respiratory

Genitourinary

Gastrointestinal

Musculoskeletal

Skin

Neurological

Other

PHYSICAL EXAMINATION

System examined

Required Field = Focus area for this Bright Futures Visit

Normal examination findings in text. Cross out abnormalities. Describe other findings in the area provided

General: Well-appearing child. Normal BMI and BP for age.

Head: Normocephalic and atraumatic.

Eyes: Pupils equal, round, and reactive to light. Extraocular eye movements intact. Normal funduscopic examination findings.

Ears, nose, mouth, and throat: Tympanic membranes with visible light reflex bilaterally. Healthy-appearing teeth without visible caries.

Neck: Supple, with full range of motion and no significant adenopathy

Heart: Regular rate and rhythm. No murmur

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing

Abdomen: Soft, with no palpable masses.

Genitourinary:

Normal female external genitalia.

Normal male external genitalia.

Sexual Maturity Rating

Female: Breast development SMR

pubic hair SMR

Male: Testicular development SMR

pubic hair SMR

Musculoskeletal: Spine straight. Full range of motion in hips, knees, and ankles.

Neurological: Normal gait. Normal strength and tone.

Skin: Warm and well perfused. No rashes or bruising. No signs of cutting or other self-injury

Other comments

ASSESSMENT

Well Child

Normal Interval Growth (See growth chart)

Normal BMI percentile for age

Normal BP percentile for age

Comments:

ANTICIPATORY GUIDANCE

Discussed and/or handout given

SOCIAL DETERMINANTS OF HEALTH

Neighborhood and family violence
Food security
Family substance use
Harm from the Internet
Emotional security and self-esteem
Connectedness with family and peers

DEVELOPMENT AND MENTAL HEALTH

Temper problems, setting reasonable limits, and friends
Sexuality

SCHOOL

School attendance
School problems
School performance and progress
Transitions
Co-occurrence of middle school and pubertal transitions

PHYSICAL GROWTH AND DEVELOPMENT

Oral health
Nutrition
Physical activity

SAFETY

Car safety
Safety during physical activity
Water safety
Sun protection
Knowing child’s friends and their families
Gun safety

PLAN

Immunizations:

Immunizations:

Vaccine Administration Record reviewed

Administered today

Immunizations:

Up-to-date for age

Universal Screening

Dyslipidemia

(once between 9 y and 11 y):

Completed Age

Result

Within reference range Abnormal

Please describe if abnormal is selected

Hearing

Age 10 y

Result

Normal Hearing BL Abnormal

Please describe if abnormal is selected

Vision

Age 10 y

Result:

Normal Vision for age Abnormal

Please describe if abnormal is selected

Selective Screening (based on risk assessment) (See Previsit Questionnaire.):

Anemia

Hearing (age 9 y)

Oral Health

Tuberculosis

Vision (age 9 y)

Comments/results

Follow-up

Routine follow-up in 1 year

Next visit

Referral to:

Next Visit

Referral to

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