Pediatric Visit 17 To 20 Years Form
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1DATE OF SERVICE___________________
PEDIATRIC VISIT 17 TO 20 YEARS
NAME__________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/_____% HEIGHT__________/_____%
BMI ______/______%
TEMP_____________
BP_____________
HISTORY REVIEW/UPDATE:
NUTRITIONAL ASSESSMENT:
(note changes)
Medical history updated? ______________________________
Typical diet
:
(specify foods)
Family health history updated? _________________________
Symptoms of eating disorder? Yes / No
Reactions to immunizations? Yes / No____________________
Physical Activities:
Concerns: _________________________________________
At least 1hr. exercise daily? Yes / No
Education: Select healthy foods
Use skim milk/and lowfat foods
PSYCHOSOCIAL ASSESSMENT:
Recent changes in family:
(circle all that apply)
Avoid fad diets
2 hrs or less of TV/computer games
New members, separation, chronic illness, death, recent move,
5 fruits/vegetables daily
No sweetened beverages
loss of job, other___________________________
Vitamin/mineral supplements, folic acid for females
Eat breakfast
Environment: Smokers in home? Yes / No
DEVELOPMENTAL SURVEILLANCE:
Violence Assessment:
(interview separately)
Name of School:
Any fears of partner/other violence? Yes / No
Grade:
Performance:
Access to gun/weapon?
Yes / No
Peer Relations:
SUBSTANCE ABUSE ASSESS/SCREENING:
Family Relations:
Pos / Neg For: ________________ Counseled? Yes / No
Extracurricular activities:
Referral: Yes / No
To:____________________________
Misc. issues:
RISK ASSESSMENT:
CHOL
TB
STI/HIV
ANTICIPATORY GUIDANCE:
Pos / Neg Pos / Neg Pos / Neg
(Circle)
Social: Love life
Peer groups pressures
Mood swings
Social misconduct resulting from family dysfunctions
MENTAL HEALTH ASSESSMENT:
Establishing own values
Future plans
Stay in school
Problem identified? No / Yes Counseling provided? No / Yes
Referral? No / Yes To: _____________________________
Parenting: Support
Prepare for independence
Health: Dental care
Fluoride
Personal hygiene
Smoking
PHYSICAL EXAMINATION
Second hand smoke
Menstruation
Breast/testicular self-exam
Wnl
Abn
(describe abnormalities)
Appearance/Interaction
Physical activity
Use sunscreen
Tick prevention
Growth
Sexuality: Birth control
Sexual Responsibility
STDs
___________________________________
Injury prevention: Seat belt
Bicycle helmets
Skin
Protective devices in sports
Smoke detector/escape plan
Head/Face
Eyes/Red reflex
Firearms (owner risk/safe storage)
Alcohol/drug use
Cover test/Eye muscles
Ears
PLANS/ORDERS/REFERRALS
Nose
1. Review immunizations and bring up to date
__________________
Mouth/Gums/Dentition
2. PPD if positive risk assessment
___________________________
___________________________________
3. Testing/counseling if positive cholesterol risk assessment
_______
Neck/Nodes
4. Testing if positive STD/HIV risk assessment
_________________
Lungs
5. Dental visit advised
or date of last visit
___________________
___________________________________
6. Next preventive appointment at _____________________________
Heart/Pulses
7. Referrals for identified problems: Yes / No (specify)
Chest/Breasts
__________________________________________________________
___________________________________
Abdomen
__________________________________________________________
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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