Pediatric Visit 14 To 16 Years Form
Download a blank fillable Pediatric Visit 14 To 16 Years Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Pediatric Visit 14 To 16 Years Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1DATE OF SERVICE___________________
PEDIATRIC VISIT 14 TO 16 YEARS
NAME__________________________________________
M / F
DATE OF BIRTH______________
AGE_____________
WEIGHT__________/_____%
HEIGHT__________/_____%
BMI ______/______%
TEMP_____________
BP_____________
(note changes)
Nutritional Assessment:
HISTORY REVIEW/UPDATE:
Medical history updated? Yes / No_______________________
Typical diet
:
(specify foods)
Family health history updated? Yes / No__________________
Symptoms of eating disorder?
Yes / No
Reactions to immunizations? Yes / No____________________
Physical Activities:
Concerns: _________________________________________
At least 1hr. exercise daily? Yes / No
PSYCHOSOCIAL ASSESSMENT:
Education: Food sources of iron, calcium, folic acid
Recent changes in family:
(circle all that apply)
Select healthy foods
Prevent obesity
Eat breakfast
New members, separation, chronic illness, death, recent move,
Avoid eating disorders/fad diets
2 hrs or less of TV/computer games
loss of job, other___________________________
5 fruits/vegetables daily
No sweetened beverages
Environment: Smokers in home? Yes / No
Violence Assessment:
DEVELOPMENTAL SURVEILLANCE:
(interview separately)
Name of School: Grade:
Performance:
Any fears of partner/other violence? Yes / No
Access to gun/weapon? Yes / No
Peer Relations:
Family Relations:
SUBSTANCE ABUSE ASSESS/SCREENING:
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: Confidentiality
Peer group pressures
Mood swings
Dependence vs. independence
Establishing own values
MENTAL HEALTH ASSESSMENT:
Social misconduct due to family dysfunctions
Future plans
Problem identified?
Yes / No _________________________
Stay in school
Love life
ETOH use
Drug Abuse
Counseling provided? Yes / No _______________________
Parenting: Establish fair, negotiable rules
Allow decisions
Referral? Yes / No To: ______________________________
Provide support, encouragement
Money, allowance
Promote mutual respect
Respect privacy
PHYSICAL EXAMINATION
Wnl
Abn
(describe abnormalities)
Health: Dental care
Personal hygiene
Fluoride
Menstruation
Appearance/Interaction
Breast/testicular self-exam
Smoking
Second hand smoke
Use
Growth (symptoms of eating disorders?)
sunscreen
Tick prevention
___________________________________
Sexuality: Prepare for physical changes
Birth control
STDs
Skin
Sexual Responsibility
Head/Face
Eyes/Red reflex
Injury prevention: Seat belt
Alcohol/drug use
Bicycle helmets
Cover test/Eye muscles
Protective devices in sports
Water safety
Ears
Smoke detector/escape plan
Firearms (owner risk/safe storage)
Nose
Mouth/Gums/Dentition
PLANS/ORDERS/REFERRALS
___________________________________
1. Review immunizations and bring up to date __________________
Neck/Nodes
2. PPD, if positive risk assessment
___________________________
Lungs
3. Recommend Objective Hearing and Vision Tests ______________
___________________________________
4. Testing/counseling if positive cholesterol risk assessment
_______
Heart/Pulses
Chest/Breasts
5. Testing if positive STD/HIV risk assessment __________________
___________________________________
6. Dental visit advised
or date of last visit______________________
Abdomen
7. Next preventive appointment at ______________________________
Genitals/Tanner Stage/Pelvic/GU
8. Referrals for identified problems: Yes / No (specify)
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical