Visit Documentation Form: 15 Through 17 Year Visit

Please correct the errors described below.

Well Adolescent

HISTORY

Nutrition

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 (Discussed and/or handout given )

  • Interpersonal violence
  • Living situation and food security
  • Family substance use
  • Connectedness with family, peers, and community
  • School performance
  • Coping with stress and decision-making
  • Family rules and routines, concern for others, and respect for others
  • Patience and control over anger
  • Oral health
  • Body image
  • Healthy eating
  • Physical activity and sleep
  • Mood regulation and mental health
  • Sexuality
  • Pregnancy and sexually transmitted infections
  • Tobacco, e-cigarettes, alcohol, and prescription or street drugs
  • Acoustic trauma
  • Seat belt and helmet use
  • Sun protection
  • Firearm safety
  • Substance use and riding in a vehicle

PLAN

Universal Screening

Follow-up

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