|
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
|
|
|
Discussed vaccines/deferred
• • •
|
|
|
|
|
|
Additional Information
|
|
