Pediatric Visit 12 To 13 Years Form - Md Healthy Kids Program
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1DATE OF SERVICE___________________
PEDIATRIC VISIT 12 TO 13 YEARS
NAME______________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/_____%
HEIGHT__________/_____%
BMI ______/______% TEMP______________
BP_____________
(note changes)
HISTORY REVIEW/UPDATE:
NUTRITIONAL ASSESSMENT:
Medical history updated? ______________________________
Typical diet:
:
(specify foods)
Family health history updated? _________________________
Symptoms of eating disorders? Yes / No
Reactions to immunizations? Yes / No____________________
Physical Activities:
Concerns: _________________________________________
At least 1hr. exercise daily? Yes / No
Education: Choose variety of foods
Sociable at table
PSYCHOSOCIAL ASSESSMENT:
Recent changes in family:
(circle all that apply)
Avoid fad diets/eating disorders
Select healthy snacks
New members, separation, chronic illness, death, recent move,
5 fruits/vegetables daily
2 hrs or less of TV/computer games
loss of job, other____________________________________
:
Environment: Smokers in home? Yes / No
DEVELOPMENTAL SURVEILLANCE
Name of School: Grade:
Performance:
Violence Assessment:
(interview separately)
Peer Relations:
Any fears of partner/other violence? Yes / No
Access to gun/weapon?
Yes / No
Family Relations:
Extracurricular activities:
SUBSTANCE ABUSE ASSESS/SCREENING:
Misc. issues:
Pos / Neg For: ________________ Counseled? Yes / No
Referral: Yes / No
To:____________________________
ANTICIPATORY GUIDANCE:
Social: Family and peer activities
Ownership and competition
MENTAL HEALTH ASSESSMENT:
Responsibility for self and family
ETOH use
Drug Abuse
Problem identified?
Yes / No ________________________
Counseling provided? Yes / No
_____________________
Parenting: Establish fair, negotiable rules
Money, allowance
Promote mutual & self-respect
Respect privacy
Allow decisions
Referral? Yes / No To: ____________________________
Spend time with child talking, projects
RISK ASSESSMENT:
CHOL
TB
STI/HIV
Play and communication: Organized sports
Pos / Neg Pos / Neg Pos / Neg
(Circle)
Monitor TV and internet use
Health: Dental care
Fluoride
Personal hygiene
Smoking
PHYSICAL EXAMINATION
Second hand smoke
Use sunscreen
Tick prevention
Wnl
Abn
(describe abnormalities)
Appearance/Interaction
Sexuality: Prepare for physical changes
Masturbation
Growth
Modesty
Sexual Responsibility
STDs
_____________________________
Injury prevention: Seat belt
Bicycle helmet
Riding in traffic
Skin
Smoke detector/escape plan
Poison control #
Water safety
Head/Face
Protective devices in sports
Alcohol/drug use
Eyes/Red reflex
Firearms (look alike toys; owner risk/safe storage)
Cover test/Eye muscles
Ears
PLANS/ORDERS/REFERRALS
Nose
1. Review immunizations and bring up to date __________________
Mouth/Gums/Dentition
2. Recommend objective Hearing and Vision Tests ______________
_____________________________
3. PPD if positive risk assessment ___________________________
Neck/Nodes
Lungs
4. Testing/counseling if positive cholesterol risk assessment
______
_____________________________
5. Testing if positive STD/HIV risk assessment __________________
Heart/Pulses
6. Testing for sickle cell trait if original metabolic results not available
Chest/Breasts
7. Dental visit advised
or date of last visit______________________
_____________________________
8. Next preventive appointment at _____________________________
Abdomen
9. Referrals for identified problems: Yes / No (specify)______________
Genitals/Tanner Stage/Pelvic/GU
Age at menarche ______ LMP__________
________________________________________________
Musculoskeletal
________________________________________________
Neuro/Reflexes
_____________________________
________________________________________________
Vision (gross assessment)
________________________________________________
Hearing (gross assessment)
Signatures:__________________________________________________________________________________________________
Maryland Healthy Kids Program
2014
https://mmcp.dhmh.maryland.gov/epsdt
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