Pertinent reviews completed
|
|
General Exam Adult and Child
|
|
General
|
General
• • •
|
General Comments
|
|
HEENT
|
HEENT expanded
• • •
|
HEENT Comments
|
HEENT moderate exam
• • •
|
Skin
|
Skin
• • •
|
Skin Comments
|
Skin diagram
|
Neck
|
Neck
• • •
|
Neck Comments
|
|
Cardiovascular
|
Cardiovascular expanded
• • •
|
Cardiovascular Comments
|
Cardiovascular moderate
• • •
|
Pulmonary
|
Pulmonary
• • •
|
Lungs Comments
|
|
Abdomen
|
Abdomen
• • •
|
Abdomen Comments
|
|
Musculoskeletal
|
MSK
• • •
|
MSK Comments
|
|
Breasts
|
Breasts
• • •
|
Breasts Comments
|
|
Neuro
|
Neuro expanded
• • •
|
Neuro Comments
|
Neuro limited
• • •
|
Extremities
|
Extremities expanded
• • •
|
Extrem Comments
|
Extremities limited
• • •
|
Genitourinary - Female
|
Female GU expanded
• • •
|
GU female comment
|
Female GU limited
• • •
|
Genitourinary - Male
|
Male GU expanded exam
• • •
|
GU male comments
|
Male GU limited
• • •
|
Mental Health
|
Mental Health
• • •
|
Newborn/Infant Exam
|
Newborn/Infant General
• • •
|
Newborn/Infant Head, Face, and Neck
• • •
|
Newborn chest
• • •
|
Newborn/Infant Pulmonary
• • •
|
Newborn/infant Cardiovascular
• • •
|
Newborn/Infant upper extremities
• • •
|
Newborn/Infant Abdomen
• • •
|
Newborn/Infant Genitalia
• • •
|
Newborn/Infant Hips and lower extremities
• • •
|
|
|
|
|
|
|
|
|
|
|
|
|
PEDIATRIC WELLNESS BY AGE GROUP
|
|
PEDIATRIC WELLNESS BY AGE
|
|
Infant 2-5 days
|
|
Term?
|
Pre-Term?
|
Gestation
|
Gestation +days
|
APGAR 1 minute
|
APGAR 5 minutes
|
APGAR 10 minutes
|
Birth Weight - Pounds
|
Birth Weight - Ounces
|
Discharge Weight - Pounds
|
Discharge Weight - Ounces
|
Hearing Screen
|
Pulse Ox Screen Normal?
|
Maternal Blood Type
|
Infant Blood Type
|
Direct Coombs
|
Bilirubin screening
|
Bilirubin Value
|
Hep B Vaccine Date
|
Neonatal Complications
• • •
|
Birth History Comments
|
Family History - Childhood/birth impairment
|
Nutrition
• • •
|
Breastfeeding minutes per feed
|
Breastfeeding Hours between feed
|
Problems breastfeeding
• • •
|
Lactation Consultant Recommended
|
Formula Type
|
Ounces per Feeding
|
Vitamins?
|
Elimination
• • •
|
Elimination Comments
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
Anticip. Guidance - Newborn Tran
• • •
|
Anticip. Guidance - Newborn Care
• • •
|
Anticip. Guidance - Nutrition
• • •
|
Anticip. Guidance - Parental Wel
• • •
|
Vaccines Discussed
|
Vaccines refused by parent/guardian
• • •
|
Additional Information on vaccines
|
|
2 Month/8 weeks of age
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Parents Adjusting Well?
|
Adjustment Comments
|
Signs of Post-Partum Depression?
|
PPD Comments
|
Sibling Adjusting Well?
|
Sibling Adjustment Comments
|
Work/Child Care Plans
• • •
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Breastfeeding minutes per feed
|
Breastfeeding Hours between feed
|
Problems Breastfeeding
• • •
|
Formula Type
|
Ounces per Feeding
|
Vitamins
|
Elimination
• • •
|
Development - Cognitive
• • •
|
Development - Social/Emotional
• • •
|
Development - Physical
• • •
|
Development - Communicative
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Parental Wel
• • •
|
Anticip. Guidance - Infant Behav
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Nutrition
• • •
|
Vaccines Discussed/VIS Given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
6 Month
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Parents Adjusting Well?
|
Adjustment Comments
|
Sibling Adjusting Well?
|
Sibling Adjustment Comments
|
Work/Child Care Plans
• • •
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Solids Intake
• • •
|
Breastfeeding minutes per feed
|
Breastfeeding Hours between feed
|
Problems Breastfeeding
• • •
|
Formula Type
|
Ounces per Feeding
|
Vitamins
|
Elimination
• • •
|
Sleep Normal
|
Sleep Comments
|
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Infant Behav
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Nutrition
• • •
|
Anticip. Guidance - Oral Health
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
9 month well child
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Solids Intake
• • •
|
Breastfeeding minutes per feed
|
Breastfeeding Hours between feed
|
Problems Breastfeeding
• • •
|
Formula Type
|
Ounces per Day
|
Solids
• • •
|
Solids Comments
|
Vitamins
|
Elimination
• • •
|
Elimination Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior Normal
|
Behavior Comments
|
Activity Normal
|
Activity Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
Development - Cognitive
• • •
|
Development - Social/Emotional
• • •
|
Development - Physical
• • •
|
Development - Communicative
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Family Adapt
• • •
|
Anticip. Guidance - Infant Indep
• • •
|
Anticip. Guidance - Feeding
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
12 Month/1 Year visit
|
|
12 Month/1 Year old visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Solids Intake
• • •
|
Breastfeeding minutes per feed
|
Breastfeeding Times per day
|
Problems Breastfeeding
• • •
|
Formula Type
|
Ounces per Feeding
|
Vitamins
|
Vitamin Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior Normal
|
Behavior Comments
|
Activity Normal
|
Activity Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Family Suppo
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Feeding
• • •
|
Anticip. Guidance - Establish Ro
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
15 month visit
|
|
15 Month Visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Milk Type
|
Ounces milk per day
|
Breastfeeding minutes per feed
|
Breastfeeding Times per day
|
Formula Type
|
Problems Breastfeeding
• • •
|
Ounces per Feeding
|
Drinks juice
|
Ounces of Juice per day
|
Vitamins
|
Vitamins Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior Normal
|
Behavior Comments
|
Activity Normal
|
Activity Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
Development - Cognitive
• • •
|
Development - Social/Emotional
• • •
|
Development - Physical
• • •
|
Development - Communicative
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Social Devel
• • •
|
Anticip. Guidance - Establish Ro
• • •
|
Anticip. Guidance - Discipline
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
18 Month Visit
|
|
18 month visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Has Dental Home
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Milk Type
|
Ounces milk per day
|
Breastfeeding Times per Day
|
Formula Type
|
Ounces per day
|
Drinks juice
|
Ounces of Juice per day
|
Vitamins
|
Vitamins Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior Normal
|
Behavior Comments
|
Activity Normal
|
Activity Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
|
Development - Cognitive
• • •
|
Development - Social/Emotional
• • •
|
Development - Physical
• • •
|
Development - Communicative
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Development
• • •
|
Anticip. Guidance - Language Pro
• • •
|
Anticip. Guidance - Family Suppo
• • •
|
|
Anticip. Guidance - Toilet Train
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
|
Additional Information
|
2 Year Old visit
|
|
2 Year old visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Has Dental Home
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Milk Type
|
Ounces milk per day
|
Breastfeeding Times per Day
|
Formula Type
|
Ounces per day
|
Drinks juice
|
Ounces of Juice per day
|
Vitamins
|
Vitamins Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Toilet Training
|
Toilet Training Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior/Temperament Normal
|
Behavior Comments
|
Play Time 60 min/day
|
Activity Comments
|
Screen Time <2 hours/day
|
Screen Time Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
|
Development - Cognitive
• • •
|
Development - Social/Emotional
• • •
|
Development - Physical
• • •
|
Development - Communicative
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Behavior/Dev
• • •
|
Anticip. Guidance - Language Pro
• • •
|
Anticip. Guidance - TV Viewing
• • •
|
|
Anticip. Guidance - Toilet Train
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
|
Additional Information
|
2-1/2 Year Old Visit
|
|
2-1/2 year old visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Has Dental Home
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Milk Type
|
Ounces of milk per day
|
Breastfeeding Times per Day
|
Drinks juice
|
Ounces of Juice per day
|
Other Nutrition
|
Vitamins
|
Vitamins Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Toilet Training
|
Toilet Training Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior/Temperament Normal
|
Behavior Comments
|
Play Time 60 min/day
|
Activity Comments
|
Screen Time <2 hours/day
|
Screen Time Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - Social Devel
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - TV Viewing
• • •
|
Anticip. Guidance - Language Pro
• • •
|
Anticip. Guidance - Toilet Train
• • •
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
4 Year Old Visit
|
|
4 year old visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Has Dental Home
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Milk Type
|
Ounces milk per day
|
Breastfeeding Times per Day
|
Drinks juice
|
Ounces of Juice per day
|
Other Nutrition
|
Vitamins
|
Vitamins Type
• • •
|
Elimination
• • •
|
Elimination Comments
|
Toilet Training
|
Toilet Training Comments
|
Sleep Normal
|
Sleep Comments
|
Behavior/Temperament Normal
|
Behavior Comments
|
Play Time 60 min/day
|
Activity Comments
|
Screen Time <2 hours/day
|
Screen Time Comments
|
Social/Family changes since last
|
Changes Comments
|
Parents Working Outside Home
• • •
|
Child Care?
|
Childcare Type
• • •
|
Pre-School?
|
Pre-School Days per week
|
Doing Well in Pre-School
|
Pre-School Comments
|
Development - Social/Emotional
• • •
|
Development - Cognitive
• • •
|
Development - Communicative
• • •
|
Development - Physical
• • •
|
Developmental Delay concerns?
|
|
Anticip. Guidance - School Readi
• • •
|
Anticip. Guidance - Personal Hab
• • •
|
Anticip. Guidance - TV Viewing
• • •
|
Anticip. Guidance - Family Invol
• • •
|
Anticip. Guidance - Safety
• • •
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
5-6 Year Old visit
|
|
5-6 Year Old
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Vitamins
|
Sleep Normal
|
Sleep Comments
|
Play Time 60 minutes/day?
|
Screen Time <2 hours/day?
|
Grade
|
Special Education?
|
School Performance
• • •
|
Special Education Comments
|
School Performance Negative
• • •
|
Negative School Performance Comm
|
School Performance Comments
|
Sports
• • •
|
Other after-school activities
• • •
|
Home situation good?
|
Home Situation Comments
|
After School Care
|
After School Care Description
|
Gets along well with siblings?
|
Sibling Comments
|
Family History of Early Heart Di
|
Risk Factors for SCA
|
Development - Motor
• • •
|
Development - Language
• • •
|
Development - Learning
• • •
|
Developmental Delay concerns?
|
Anticip. Guidance - Dev./Mental
• • •
|
Anticip. Guidance - School
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Nutrition
• • •
|
|
Anticip. Guidance - Oral Health
• • •
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
|
Additional Information
|
7-8 year old wellness
|
|
7-8 year old wellness
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Vitamins
|
Sleep Normal
|
Sleep Comments
|
Play Time 60 minutes/day?
|
Screen Time <2 hours/day?
|
Grade
|
Special Education?
|
School Performance
• • •
|
Special Education Comments
|
School Performance Negative
• • •
|
School Performance Comments
|
Sports
• • •
|
Negative School Performance Comm
|
Other after-school activities
• • •
|
Home situation good?
|
Home Situation Comments
|
Gets along well with siblings?
|
Sibling Comments
|
Family History of Early Heart Di
|
Risk Factors for SCA
|
Anticip. Guidance - School
• • •
|
Anticip. Guidance - Dev./Mental
• • •
|
Anticip. Guidance - Nutrition
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Oral Health
• • •
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
9-10 year old
|
|
9-10 year old
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Medication Record Reviewed
|
Changes since last visit?
|
Changes comments
|
Nutrition
• • •
|
Nutrition Comments
|
Vitamins
|
Sleep Normal
|
Sleep Comments
|
Play Time 60 minutes/day?
|
Screen Time <2 hours/day?
|
Grade
|
Special Education?
|
School Performance
• • •
|
Special Education Comments
|
School Performance Negative
• • •
|
School Performance Comments
|
Sports
• • •
|
Negative School Performance Comm
|
Other after-school activities
• • •
|
Home situation good?
|
Home Situation Comments
|
Gets along well with siblings?
|
Sibling Comments
|
Family History of Early Heart Di
|
Risk Factors for SCA
|
Anticip. Guidance - School
• • •
|
Anticip. Guidance - Dev./Mental
• • •
|
Anticip. Guidance - Nutrition
• • •
|
Anticip. Guidance - Safety
• • •
|
Anticip. Guidance - Oral Health
• • •
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
Additional Information
|
|
11-14 year old visit
|
|
11-14 year old visit
|
|
Interval History
• • •
|
Parental Concerns
• • •
|
Parental concerns comments
|
Menarche
|
Menses
• • •
|
Medication Record Reviewed
|
Home situation good?
|
Home Situation Comments
|
Gets along well with siblings?
|
Sibling Comments
|
Teen Lives with
• • •
|
Lives with other
|
Family History of Early Heart Dz
|
Risk Factors for SCA
|
Home: Meals with family?
|
Home: Has adult to turn to?
|
Home: Makes independent decisio
|
Education: Grade
|
Education: Performance
|
Education: Behavior/Attention
|
Behavior/Attention Comment
|
Eating: Well-Balanced diet
|
Eating: Non-sweetened liquids?
|
Eating: Adequate Calcium/Vit. D
|
Eating: Body appearance concern
|
Activities: Has friends?
|
Activities: 1 hr physical activ
|
Activities: Screen time <2 hrs/
|
Activities: Sports
• • •
|
Activities: Musical Instruments
|
Activities: Other
|
Discussed tobacco/drugs/alcohol
|
Safety: Home Free of Violence?
|
Safety: Uses seatbelts/helmets/
|
Safety: Peer relationships w/o
|
Discussed Sex
|
Ment.Health: Able to cope with
|
Ment.Health: Displays self-conf
|
Ment.Health: Problems with slee
|
Ment.Health: Gets depressed/anx
|
Ment.Health: Suicidal thoughts
|
Mental Health Comments
|
Anticip. Guidance - Growth/Devel
• • •
|
Anticip. Guidance - Social/Acade
• • •
|
Anticip. Guidance - Emotional We
• • •
|
Anticip. Guidance - Risk Reducti
• • •
|
Anticip. Guidance - Violence/Inj
• • •
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
|
Additional Information
|
15-21 year old visit
|
|
15-21 year old
|
|
Interval History
• • •
|
Parental Concerns
• • •
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Parental concerns comments
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Menarche
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Menses
• • •
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Menses Comments
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Medication Record Reviewed
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Home situation good?
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Home Situation Comments
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Gets along well with parents/sib
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Sibling Comments
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Teen Lives with
• • •
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Lives with other
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Family History of Early Heart Dz
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Risk Factors for SCA
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Home: Meals with family?
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Home: Has adult to turn to?
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Home: Makes independent decisio
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Education: Grade
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Education: Performance
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Education: Behavior/Attention
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Behavior/Attention Comment
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Eating: Well-Balanced diet
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Eating: Non-sweetened liquids?
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Eating: Adequate Calcium/Vit. D
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Eating: Body appearance concern
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Activities: Has friends?
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Activities: 1 hr physical activ
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Activities: Screen time <2 hrs/
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Activities: Sports
• • •
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Activities: Musical Instruments
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Activities: Other
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Discussed tobacco/drugs/alcohol
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Safety: Home Free of Violence?
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Safety: Uses seatbelts/helmets/
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Safety: Peer relationships w/o
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Discussed Sex
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Ment.Health: Able to cope with
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Ment.Health: Displays self-conf
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Ment.Health: Problems with slee
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Ment.Health: Gets depressed/anx
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Ment.Health: Suicidal thoughts
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Mental Health Comments
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Anticip. Guidance - Growth/Devel
• • •
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Anticip. Guidance - Social/Acade
• • •
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Anticip. Guidance - Emotional We
• • •
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Anticip. Guidance - Risk Reducti
• • •
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Anticip. Guidance - Violence/Inj
• • •
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CRAFFT Questionnaire
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Car w/someone using drugs/alcoho
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Use to Relax/Feel better/fit in
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Use Alcohol/Drugs while Alone
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Forget things did while using
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Friends or Family tell you to cu
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Gotten into TROUBLE while using
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CRAFFT Questionnaire Comments
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Vaccines Discussed/VIS given
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Vaccines refused by parent/guardian
• • •
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Additional Information
|
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Sports/Camp/Child-Adolescent Pre-op exam
|
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Sports/Camp/Child-adolescent pre-op physical
|
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HPI: Sports Physical
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Front Office Signature
• • •
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Pre-Operation Clearance - Name of Surgery
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Date of Planned Surgery
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Social History -
• • •
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ROS - Pre-Op Clearance- All NEG
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ever been denied to play sports?
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Surgery?
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Ongoing Medical Conditions?
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Fainted?
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Chest Pain during exercise?
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heart skip a beat/ race during exercise?
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Any Heart Problems?
|
EKG or ECHO?
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Seizure?
|
Abnormal Shortness of Breath during exercise?
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Unexplained death in family member <50 years
|
miss a game due to an injury?
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Broken Bone?
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Joint pain?
|
Asthma?
|
Missing kidney? spleen?
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Males: do you have a hernia?
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Mono this past month?
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Concussion?
|
Blow to head --> h/a or memory loss?
|
Numbness or Tingling (EXT)?
|
Vision problems? eye injury?
|
worry about your weight?
|
eating disorder?
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FEMALES ONLY - ever had a period?
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how many periods in the past year?
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Age of your first Period?
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LAST Tdap Vaccination
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Explain "Yes" Answers here
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Vision Right Eye
/
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Vision Left Eye
/
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Vision Both Eyes
/
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Corrected Vision
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Pupils Equal (Yes)/ Unequal (No)
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MA Signature
• • •
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Appearance
|
HEENT
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Lymph Nodes
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Heart - CV
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Lungs
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Abdomen
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Genitourinary (Males only)
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Skin
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Neuro
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Musculoskeletal
• • •
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PE Abnormals - Free write here
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Cleared for Sports (Yes)
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Cleared for Sports (with EXCEPTION)
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Referral
• • •
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Not Cleared for Sports
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I have evaluated...
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Pre- Op Clearance PLAN
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Cleared for Surgery
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Name of Physician/ Provider
• • •
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