|
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
• • •
|
|
Mental Health additional comments:
|
|
|
Newborn/Infant exam
|
|
|
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
• • •
|
|
comments
|
|
|
PEDIATRIC WELLNESS BY AGE GROUP
|
|
|
PEDIATRIC WELLNESS REVIEW BY AGE
|
|
|
Infant 2-5 days
|
|
|
Term?
|
Pre-Term?
|
|
Gestation
|
|
|
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
• • •
|
|
Parental concerns comments
|
Menarche
|
|
Menses
• • •
|
Menses Comments
|
|
Medication Record Reviewed
|
Home situation good?
|
|
Home Situation Comments
|
Gets along well with parents/sib
|
|
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
• • •
|
|
CRAFFT Questionnaire
|
Car w/someone using drugs/alcoho
|
|
Use to Relax/Feel better/fit in
|
Use Alcohol/Drugs while Alone
|
|
Forget things did while using
|
Friends or Family tell you to cu
|
|
Gotten into TROUBLE while using
|
CRAFFT Questionnaire Comments
|
|
Vaccines Discussed/VIS given
|
Vaccines refused by parent/guardian
• • •
|
|
Additional Information
|
|
|
Sports/Camp/Child-Adolescent Pre-op exam
|
|
|
Sports/Camp/Child-adolescent pre-op physical
|
|
|
HPI: Sports Physical
|
Front Office Signature
• • •
|
|
Pre-Operation Clearance - Name of Surgery
|
Date of Planned Surgery
|
|
Social History -
• • •
|
ROS - Pre-Op Clearance- All NEG
|
|
ever been denied to play sports?
|
Surgery?
|
|
Ongoing Medical Conditions?
|
Fainted?
|
|
Chest Pain during exercise?
|
heart skip a beat/ race during exercise?
|
|
Any Heart Problems?
|
EKG or ECHO?
|
|
Seizure?
|
Abnormal Shortness of Breath during exercise?
|
|
Unexplained death in family member <50 years
|
miss a game due to an injury?
|
|
Broken Bone?
|
Joint pain?
|
|
Asthma?
|
Missing kidney? spleen?
|
|
Males: do you have a hernia?
|
Mono this past month?
|
|
Concussion?
|
Blow to head --> h/a or memory loss?
|
|
Numbness or Tingling (EXT)?
|
Vision problems? eye injury?
|
|
worry about your weight?
|
eating disorder?
|
|
FEMALES ONLY - ever had a period?
|
how many periods in the past year?
|
|
Age of your first Period?
|
LAST Tdap Vaccination
|
|
Explain "Yes" Answers here
|
Vision Right Eye
/
|
|
Vision Left Eye
/
|
Vision Both Eyes
/
|
|
Corrected Vision
|
Pupils Equal (Yes)/ Unequal (No)
|
|
MA Signature
• • •
|
Appearance
|
|
HEENT
|
Lymph Nodes
|
|
Heart - CV
|
Lungs
|
|
Abdomen
|
Genitourinary (Males only)
|
|
Skin
|
Neuro
|
|
Musculoskeletal
• • •
|
PE Abnormals - Free write here
|
|
Cleared for Sports (Yes)
|
Cleared for Sports (with EXCEPTION)
|
|
Referral
• • •
|
Not Cleared for Sports
|
|
I have evaluated...
|
Pre- Op Clearance PLAN
|
|
Cleared for Surgery
|
Name of Physician/ Provider
• • •
|
