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History
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Concerns and questions
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Follow-up on previous Concerns
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History Interval Change
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History Interval Change
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Social/Family History/Situation
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Family Situation Interval Change
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Family Situation Interval Change
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Teen lives with whom?
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Pets in house
• • •
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Pet Comments
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Changes since last visit
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Screened for Domestic Violence?
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Review of Systems
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Interval Change
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Changes since last visit
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Nutrition: Special Diet?
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Toxic Exposure: Passive Smoking
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TB risk
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Cholesterol risk
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School Life
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Grade
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Grade Comments
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Social Interaction
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Social Interaction Comments
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Performance
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Performance Comments
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Behavior
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Behavior Comments
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Attention
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Attention Comments
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Homework
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Homework Comments
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Parent/Teacher Concerns
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Home Life
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Cooperation
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Sibling Interaction
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Oppositional Behavior
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Parent Concerns
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Daily Exercise
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Minutes/day
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Type of Exercise
• • •
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Physical Exam
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Appearance Normal?
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Appearance Comments
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Skin Normal?
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Skin Comments
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Head Normal?
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Head Comments
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Eyes Normal?
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Eyes Comments
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Ears Normal?
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Ears Comments
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Nose Normal?
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Nose Comments
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Mouth/Throat/Teeth/Gums Normal?
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Mouth/Throat/Teeth/Gums Comments
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Nodes Normal?
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Nodes Comments
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Heart Normal?
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Heart Comments
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Lungs Normal?
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Lungs Comments
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Abdomen Normal?
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Abdomen Comments
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Femoral Pulse Normal?
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Femoral Pulse Comments
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External Genitalia Normal?
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Ext. Genitalia Comments
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Extremities Normal?
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Extremities Comments
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Spine Normal?
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Spine Comments
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Neuro Normal?
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Neuro Comments
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Other
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Other Comments
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Assessment
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Well Child?
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Further Comments
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Anticipatory Guidance
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Nutrition
• • •
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Dental Care
• • •
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Sleep
• • •
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Cognitive
• • •
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Social
• • •
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Parenting and Discipline
• • •
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Injury Prevention
• • •
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Teen Driving
• • •
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Plan
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Plan
• • •
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Plan Comments
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Discussed Worsening Symptoms?
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Referrals
• • •
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Labs Ordered
• • •
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Additional
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Previous Lab Results
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Follow-up/Next visit
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Immunizations
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Immunizations Administered
• • •
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Immunization Status
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Final Check
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Discussed condition?
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D/W whom?
• • •
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Chart History Reviewed?
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