_ 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.
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
Menses started at age _, and is regular.
- No smokers in the home.
- No TB or lead risk factors.
- Plans after high school: _
- Up to date.
- 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.
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
* 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