Well Child Visit Form-15-21 Years printable pdf download

Well Child Visit: 15-21 Years

Name: __________________________________

DOB: ________________ Date: __________________

Current Medications

Drug/ Food Allergies

Accompanied By

Age

Ht.

Wt.

BMI

BMI %ile

Pulse

Interpreter: Y / N

□M

□F

Past Medical History

Risk Assessment/ HEEADSSS

Recent illness/injury: □ Yes □No ________________

HOME

Lives with:__________________

Parent/teen interaction: □ NL _________

Has a dental home: □ Yes □No _________________

Family meals: □ Yes □No

Has family mbr/adult can turn to for help: □ Yes □No

Last dentist visit was: _____________

EDUCATION

Performance: □ NL ________

Future plans: □ Yes □No

Menarche: Age_____

Regular □ Yes □No _______

Grade Level:______

EATING

Balanced diet: □ Yes □No

Calcium: □ Yes □No

Sugary drinks: □ Yes □No

Parent/Teen Concerns:

____________________________________________

Snack habits: □ NL ______

Body Image: □ NL ____________

____________________________________________

ACTIVITIES

Has friends □ Yes □No Hobbies: □ Yes □No Involved in community: □ Yes □No

____________________________________________

Exercises >60 mins/day □ Yes □No

Activities/sports: ___________________

____________________________________________

Screen time <2hr/day □ Yes □No

____________________________________________

DRUGS (substance use/abuse)

Uses Tobacco/ETOH: □ Yes □No __________

CRAFFT Screening: □ N/A □ NL

SAFETY

Identified Risks:

Dating violence:□ Yes □No Seat Belt: □ Yes □No Distracted Driving □ Yes □No

□ None _____________________________________

Chat rooms: □ Yes □No Bullied/Bullying: □ Yes □No Tanning Salon: □ Yes □No

____________________________________________

SEX

____________________________________________

Has had oral sex: □ Yes □No

sexual intercourse: □ Yes □No # partners: _____

____________________________________________

Uses protection: □ Yes □No

Hx of STI: □ Yes □No _______________________

____________________________________________

SUICIDE/MENTALHEALTH

____________________________________________

Has self-confidence: □ Yes □No

problems with sleep: □ Yes □No

Gets depressed/anxious: □ Yes □No

Has thought about hurting self: □ Yes □No

PHQ-9 □ N/A □ NL _________________

Physical Exam (checked □ = normal)

Abnormal Findings

□ General (Alert, NAD, +eye contact)

□ Heart (No murmurs)

□ Head (No deformities, symmetric)

□ Lungs (Clear breath sounds)

□ Eyes (PERRL, EOMI, + RR, lids NL,

□ Abdomen (Soft, non-tender, no masses)

□ Skin (No rashes, no lesions, no acne)

conjunctivae/sclera clear)

□ Ears (Canals clear, TMs normal, orients

□ Neuro (Tone, symmetry, strength, & gait NL)

□ Extremities (Full ROM, strength/tone NL)

to sounds, voice)

□ Nose (Mucosa NL, patent)

□ Back (No excessive curve)

□ Mouth/Throat (MMM, lips & tongue NL

□ Genitalia Tanner Stage: ____________

no oral lesions, no erythema, thyroid NL)

Male (Penis NL: circ/uncir, no adhesions)

□ Teeth (Gums NL, dentition NL, no staining,

Female (Labia/clitoris NL, no discharge)

□Pelvic exam: □NL_________________

caries or white spots)

Assessment

Anticipatory Guidance

□ Well child

□ Healthy Habits (Brush teeth 2x/day, routine dentist visits, exercise daily,

□ Normal growth and development

balanced diet, healthy snacks, limit screen time, adequate sleep, self-

testicular/breast exams)

□ Safety (Texting & driving, abstinence/protected sex, peer pressure, tanning

salons, steroid use, no guns)

□ Learning (Future plans, frustrations & dropping out, college career)

□ Behavior (Respect limits and consequences, trust feelings, coping with stress,

seek help if feeling depressed/anxious)

Plan

□ Immunizations (See immunization record)

□ Vision acuity: R___/___

L___/___ Both___/___

□ Dental referral

Next Appointment: _________________ Signature: ___________________________ Date: _____________

0814.QI.P.FO.1 10/14

Well Child Visit Form-15-21 Years

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