15 To 20 Year Visit Form
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115 to 20 Year Visit
Date _______________________
Form revised 10/12
Name _____________________________________________ Birth Date _________________ Age ___________
Historian ________________ Allergies __________________ Medications _______________________________
Weight______lbs. _____ oz.
Height _________in.
BMI ________ %tile
Temp. _______
AX Oral
Physical Exam
B/P: ________ / ________
Undressed: o yes
o no
Nutrition
General ------------------ o nl o abnl
Low fat milk?
o Yes
o No
Head ---------------------- o nl o abnl
Variety of fruits, vegetables? o Yes
o No
Neck ---------------------- o nl o abnl
Eats breakfast?
o Yes
o No
Eyes ---------------------- o nl o abnl
Eats supper with family? o Yes
o No
Ears ---------------------- o nl o abnl
Interval History/New Problems
Nose ---------------------- o nl o abnl
Throat/Mouth/Teeth -- o nl o abnl
Change in family history? o Yes
o No
Chest
If Yes, what? _______________________
Breasts/Tanner Stage -- o nl o abnl
__________________________________
Lungs--------------------- o nl o abnl
Are there new problems or illnesses since
Heart --------------------- o nl o abnl
the last visit?
o Yes
o No
Abdomen ---------------- o nl o abnl
If Yes, what? _______________________
Femoral Pulses --------- o nl o abnl
__________________________________
Extremities -------------- o nl o abnl
Dyslipidemia Risk Assessment — +
Genitalia/Tanner Stage
Female o
Male o
FH CVD heart disease <55 M o Yes
o No
Musculoskeletal Exam
FH CVD heart disease <65 F o Yes
o No
Shoulder/arm ----------- o nl o abnl
FH cholesterol
o Yes
o No
Elbow/foremarm ------- o nl o abnl
BP > 90% ___ DM ___ inactive ____
Wrist/hand/fingers ---- o nl o abnl
passive smoke ____ Chronic illness ___
Hips/thigh --------------- o nl o abnl
BMI > 95% ____
Knee ---------------------- o nl o abnl
Do you have any problems seeing
Leg/ankle ---------------- o nl o abnl
or hearing? ________________________
Foot/toes ----------------- o nl o abnl
Hearing Risk Assessment*
— +
Safety
Social/Behavioral
(continued)
Vision Risk Assessment*
— +
o Driving and automobile safety
o Social Media
(test at age 15 & 18 or q3 years)
o Sleep hygiene
o Bike helmet, safety
L near 20/ ______________ far 20/ ________
o Eating disorder screen
— +
o Smoke detectors in home
R near 20/ ______________ far 20/ ________
o Swimming, water safety
Impression
o Wears glasses, sees eye specialist
o Firearm safety
o Well Adolescent
Anemia Risk Assessment* — +
o Sunburn prevention, tanning beds
o Normal Growth
poverty ___ poor diet ____ chronic illness _____
o Normal Development
Health
Alcohol/Drug Use Assessment* — +
o ________________________________
o Healthy food choices, Ca++ intake
o ________________________________
Ethoh, drug or substance to get high — +
o Concerns about weight, body image
Plan/Referrals
TB Risk Assessment
— +
o Periods (girls) LMP____________
o Immunizations current? o Yes o No
STI Risk Assessment
o < 20-30% of calories from dietary fat
o Tdap, MCV4 Booster, Varicella, HPV, Hep B
o < 10% of calories from saturated fat
Hx of sexual activity
— +
o Influenza vaccine
o < 300 mg of cholesterol per day
Hx of IV drug use
— +
o V.I.S./Counseling
o Adequate sleep
Cervical Dysplasia Risk Assessment
o RTC at ______ years
o Acne
o Handouts
Hx of sexual activity
— +
o Encourage sports, exercise
o Cholesterol – Non-fasting Lipid Profile
Developmental/Behavioral Surveillance
o Sports form attached
o Yes o No
(17-20 years) with follow up Fasting Lipid
Do you have any concerns about your child’s
Profile if non-fasting is abnormal
Social/Behavioral
development or behavior? o Yes
o No
o Hgb (if + menarche or high risk every
o School adjustment, performance
If Yes, why? ________________________
year)__________
o Plans for work/further education
__________________________________
o Pap 3 yrs after onset sexual activity
o Tobacco use
o STD screening
Developmental Screening*
o Drug and alcohol use
o Review transition plan
(if clinically indicated)
o Dealing with stress, anger
o Parent declination of treatment ______
o Normal
o Abnormal
o Limit TV, computer time
o Referrals _______________________
School Grade____________
o Friends and fun
o ________________________________
o Boy or girl friends /dating safety
Problems?
o Yes o No
o ________________________________
o Abstinence, birth control
If Yes, what? _______________________
_______________ M.D. / P.N.P. / DO / PA
o STDs
__________________________________
PROV# ___________________________
o Family relationships
o See back for additional documentation
* see separate form
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