Visit Documentation Forms: 11-14 Year Visit

Well Child | 11-14 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

Adolescent 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

Reviewed and updated (See Medication Record.)

Allergies

No known drug allergies

Nutrition

Daily fruits and vegetables

Iron source:

Calcium source:

Daily fruits and vegetables

Comments

Body image:

No concerns

Attempting to gain or lose weight

Yes No

Comments:

Females:

Menarche age:

Regular:

Yes No

Menstrual problems:

Yes No

If yes, please describe

Regular visits

If no, please describe

Sleep

Physical Activity

If no, please describe

Screen time

Source

School

Grade

Performance

Parent/teacher concerns

Activities:

Tobacco, alcohol, and drug use:

Sexual Orientation/Gender Identity:

Sexual Activity:

Denies:

Mood:

No concerns:

DEVELOPMENT

Normal development

See Previsit Questionnaire.

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

Engages in a positive way with the life of the community

Engages in behaviors that optimize wellness and contribute to a healthy lifestyle

Engages in healthy nutrition and physical activity behaviors
Chooses safety

Demonstrates physical, cognitive, emotional, social, and moral competencies

Exhibits compassion and empathy

Exhibits resilience when confronted with life stressors

Uses independent decision-making skills

Displays a sense of self-confidence, hopefulness, and well-being

Concerns:

SOCIAL AND FAMILY HISTORY

Changes since last visit

No Interval Change

If yes, please describe

Adolescent lives with:

Relationships with parents/siblings:

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

Gastrointestinal

Genitourinary

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 adolescent. Normal BMI and BP for age.

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. No hydrocele, hernia, varicocele, or masses. No gynecomastia.

Sexual Maturity Rating

Female: Breast development SMR

pubic hair SMR

Male: Testicular development SMR

pubic hair SMR

Musculoskeletal: Spine straight without deformities. No significant scoliosis. Full range of motion.

Skin: Warm and well perfused. No acanthosis nigricans. No signs of cutting or other self-injury. No lesions or birthmarks

ASSESSMENT

Well Child

Normal BMI percentile for age

Normal BP for age

Comments:

ANTICIPATORY GUIDANCE

Discussed and/or handout given

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:

Immunizations:

Vaccine Administration Record reviewed

Administered today

Immunizations:

Up-to-date for age

Universal Screening

Depression screening

(annual ages 12–14)

Screening tool used:

Dyslipidemia

(annual ages 12–14

Screening tool used:

Dyslipidemia

(once between 9 and 11):

Completed age:

Please describe if abnormal is selected

Please describe if follow-up is selected

Hearing

(once between 11 and 14)

Completed age

Please describe if abnormal is selected

Please describe if follow-up is selected

Vision

(once age 12):

Please describe if abnormal is selected

Please describe if follow-up is selected

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

Anemia

Dyslipidemia

Hearing

HIV

Sexually transmitted infections

Tuberculosis

Vision

Comments/results

Follow-up

Routine follow-up in 1 year

Next visit

Referral to:

Next Visit

Referral to

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