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Changes since last visit?
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Changes comments
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Parental Concerns
• • •
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Parental concerns comments
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Has Dental Home
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Comments
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Vision Screening
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Comments
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Menarche
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Menses
• • •
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Home situation good?
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Home Situation Comments
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Safety: Home Free of Violence?
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Teen Lives with
• • •
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Lives with other
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Education: Grade
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School Name
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Education: Performance
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Behavior/Attention Comment
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Education: Behavior/Attention
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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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Discussed Sex
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Depression Screen
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Screen Type
• • •
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Mental Health Comments
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Additional Information
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