Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068L (07/08)

STATE OF WISCONSIN Reprinted and adapted with permission from Memee K. Chun, M.D.

GENERAL PEDIATRIC CLINIC / TEENAGER VISIT
(See Page 2 for Teenager Visit additional exams)
Completion of this form is voluntary.

Patient Name Age T Chief Concerns Height BP

Date of Birth Weight P Past Medical History General Health / illnesses

Today's Date Sex R

Family Constellation and Concerns
Household Members Concerns: (employment, separation, divorce, family relations)

Allergies Medications Hospitalizations Surgeries Injuries / burns / fractures Dental care Immunizations

Family Medical History
Asthma Cancer CVA / MI before 60 years High Cholesterol / triglycerides Depression / Psychiatric illness Diabetes HTN Renal Sickle cell anemia Substance abuse / alcoholism Sudden death (age) TB

Sexual History (if appropriate) Dating Yes No Sexually active Yes No Age at first intercourse Number of partners STD's Pregnancies ________ Ab _____ Children ______________ Fathered a child Yes No Contraceptive use Yes No Method(s) _________________________________________ Menstrual History Menarche _____________ LMP ____________ Regular Periods Yes No Cycle length flow duration Tampons pads Dysmenorrhea Meds

School History
School Failed a grade Attitude towards school Goals / Career Absences in past year Plan to drop out this year

Social
Activities / hobbies Job Sports / exercise Diet High / low weight in past year Peer relations Dating Sleep pattern Substance use (own and friends') cigarettes alcohol drugs

Immunization
HepB MMR Td Varicella

Drug Co. & Lot No.

Expiration Date

Anticipatory Guidance Breast / Testicular self exam Decision Making sexuality issues birth control parenting future Plans Nutrition Coping skills mood changes / depression stress / relief activities Safety driving / seat belts / bike helmet guns / personal security Sun Protection

General Pediatric Clinic / Teenager Visit F-1068L (07/08)

Teenager Visit (Additional Exams)
Page 2

(Cross off parts not examined or not applicable) Physical Exam N Abn Skin: Acne-Comedones / Pustular / Nodular Head: Symmetry, Scalp, Hair Eyes: EOM, Pupils, Cornia, Conjunctivae, Fundi Ears: Pinnae, Canals, Tympanic Membrane Nose: Nares, Turbinates Throat: Pharynx, Tonsils Neck: Movements, Thyroid Nodes: Axillary, Cervical, Inguinal, Submandibular Breast Tanner Stage ­ 1,2,3,4,5 Development Masses Habits: nail biting, tics, etc. Neuromuscular: Equilibrium, Motor Strength, Sensory, Coordination, Cranial Nerves, DTRs, Babinski
Spine: Posture, Hip and Shoulder Levels Lungs Heart: Rhythm, s1, s2, Murmur Abdomen: Contour, LSK, Mass

Physical Exam
Genitourinary Tanner Stage 1, 2, 3, 4, 5 Hernia Penis Testes Scrotum Pelvic Ext. Genitalia Cervix Adnexse Uterus Lab / Saline / Gram Strain

N

Abn

Gynecomastia (m) Extremities: (Gait, Range of Motion of Joints) Anus (Rectal) Sexual Development (Describe)

Assessment: (Synopsis, health promotion, description of abnormal findings.)

Plan: (Treatment, education/counseling, referral)

Laboratory Urinalysis Hgb / Hct STD panel Pap smear Rubella titer Cholesterol Other

Immunizations dT Status TB Screen MMR Status Hepatitis B

___________________________________________ SIGNATURE ­ Provider

_________________________ Date Signed