Well Child Check >12 year old

SUBJECTIVE:
 _ here for well child check. No parental or patient concerns at this time.
 Here with parent: _
 RISK ASSESSMENT (non-confidential):
 - Has never fainted before.
 - No h/o cough, chest pain, or shortness of breath with exercise.
 - Has never had a significant head injury.
 - No family history of sudden death while exercising.
 - No family history of MI or stroke before age 55.
 RISK ASSESSMENT (confidential):
 - Home: Safe, peaceful home environment. Family members all get along, more or less.
 - Education/Employment: School is going _. No problems with safety or bullying at school.
 - Eating: No concerns about body appearance. Getting sufficient calcium in diet (at least 4 servings per day). No dietary restrictions.
 - Activities: Enjoys hanging out with friends. Screen time _. Is involved in _
 - Drugs: No history of tobacco, EtOH, or drug use. No friends are using these substances.
 - Safety: No history of violent relationships at home or elsewhere.
 - Sex: Prefers _. Has not been sexually active (oral or genital) yet.
 - Suicidality/Mental Health: No concerns. No history of physical or sexual abuse. Sleeps well at night.
 PM/SH:
 Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
 OB/GYN HX:
 Menses started at age _, and is regular.
 SOCIAL:
 - No smokers in the home.
 - No TB or lead risk factors.
 - Plans after high school: _
 IMMUNIZATIONS:
 - Up to date.
 OBJECTIVE:
 - WEIGHT: BMI _ BMI _ %ile
 - GEN: Normal general appearance. NAD.
 - HEAD: NCAT.
 - EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
 - ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
 - NECK: Supple, with no masses.
 - CV: RRR, no m/r/g.
 - LUNGS: CTAB, no w/r/c.
 - ABD: Soft, NT/ND, NBS, no masses or organomegaly.
 - GU: Normal genitalia, Tanner stage _
 - SKIN: WWP. No skin rashes or abnormal lesions.
 - MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema.
 - NEURO: Normal muscle strength and tone. No focal deficits.
 LABS/STUDIES:
 - Urine dip normal.
 - Hearing screen normal.
 - Snellen testing: _
 ASSESSMENT/PLAN:
 * Healthy _ yo adolescent
 - CBC ordered. No indication for DM screening.
 - Check lipid panel 9-11 yo & 17 - 21 yo (universal rec)
 - Check HIV 15-18 yo, repeat PRN thereafter
 - Screen for depression yearly > 12 yo PHQ2: _
 - Follow in one year, or sooner PRN.
 - ER/return precautions discussed.
 * Vaccines today:
 - Influenza, HPV (0, 1-2, and 6 months, > 9 yo), Tdap (11-12), Meningococcal ACWY (11-12, boost 16 yo), Men B (16-23, or > 10 w/ incr risk)
 * Anticipatory guidance (discussed or covered in a handout given to the family)
 - Confidentiality of visit documentation.
 - Puberty, sex, abstinence, safe dating.
 - Avoiding tobacco, drugs, alcohol; and never getting into a car with someone under the influence.
 - Dealing with stress.
 - Discipline and role models.
 - Seat belts, helmets and safety gear, sunscreen
 - Internet safety, limiting screen time
 - Importance of daily exercise.
 - Obesity prevention and adequate calcium.
 - Good dental hygiene.
 - Eliminating guns from the home, or locking bullets separately