Visit Documentation Forms: 11-14 Year Visit

Please correct the errors described below.

Well Child | 11-14 Year Visits

Vitals (if indicated)

HISTORY

Females:

Physical Activity

School

DEVELOPMENT

  • Engages in healthy nutrition and physical activity behaviors
  • Chooses safety

SOCIAL AND FAMILY HISTORY

REVIEW OF SYSTEMS

Required Field = Focus area for this Bright Futures Visit

PHYSICAL EXAMINATION

Required Field = Focus area for this Bright Futures Visit

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

Genitourinary:

Sexual Maturity Rating

ASSESSMENT

ANTICIPATORY GUIDANCE

SOCIAL DETERMINANTS OF HEALTH

  • Interpersonal violence
  • Living situation and food security
  • Family substance use
  • Connectedness with family, peers, and community
  • School performance
  • Coping with stress and decision-making

DEVELOPMENT AND MENTAL HEALTH

  • Family rules and routines, concern for others, and respect for others
  • Patience and control over anger

PHYSICAL GROWTH AND DEVELOPMENT

  • Oral health
  • Body image
  • Healthy eating
  • Physical activity and sleep

EMOTIONAL WELL-BEING

  • Mood regulation and mental health
  • Sexuality

RISK REDUCTION

  • Pregnancy and sexually transmitted infections
  • Tobacco, e-cigarettes, alcohol, and prescription or street drugs
  • Acoustic trauma

SAFETY

  • Seat belt and helmet use
  • Sun protection
  • Substance use and riding in a vehicle
  • Firearm safety

PLAN

Immunizations:


Universal Screening

Follow-up

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