New York Presbyterian Hospital New York – Cornell Campus

Adolescent Well Visit (13yr – 18yr) Pediatric Primary Care IF NO PLATE, PRINT NAME, SEX AND HISTORY NO.

DOB____________AGE______________HISTORIAN____________________________ PHONE # ____________ Interval Hx

Concerns: Sleep Patterns:

Nutrition: Allergies:

Medications: Elimination:

Recreation/Exercise: Dental Care: TB Risk Factors:

Eye Care: ROS:

Menarche:

Family Relations:

School/Social Issues: School Performance/Career Plans: Tobacco/ETOH/drug use:

After school activities:

Work:

Sexual activity:

Contraception/protection:

Friendships: Mood:

Physical Exam Vitals: T_________________CO P_________________ R_________________ BP_________________

HT___________cm/________% WT__________Kg/_________%

General Appearance: Heart:

Skin: Lungs/Chest: Breasts: Tanner Stage:

Head: Abdomen: Eyes:

Vision: R____ L____ Genitalia: Tanner Stage:

Ears: Hearing: R____ L____ Extremities:

Nose: Pulses:

Pharynx: Back/Spine:

Mouth/Teeth: Neuro: Neck: Additional Findings:

Lymph nodes:

New York Presbyterian Hospital

New York – Cornell Campus

Adolescent Well Visit (13yr – 18yr) Pediatric Primary Care IF NO PLATE, PRINT NAME, SEX AND HISTORY NO.

Anticipatory Guidance Nutrition/Health

Safety

Behavior/Development

Regular meals

Seat belts

Peer group activities

1% or skim milk

Driver’s Ed.

Family time

Limit juice, sugar, salt, fatty foods

Drunk driving

Limit TV

Calcium

Curfew

Tobacco/ETOH/Drugs

Healthy snacks

Subway safety

Puberty/sex/sexuality

Tooth brushing

Sports safety

Contraception/protection

Sleep habits

Bike/skating helmets

Parental school

Exercise/sports

Violence prevention

Suggested reading

Guns, other weapons

Independent decision making

Abuse prevention (Sexual, Emotional, Physical)

ASSESSMENT/PROBLEMS PLANS Growth/Nutrition:

School/Behavior/Social:

Other Issues:

Immunization Status:

Up To Date

Delayed (explain)

Immunizations: ___risks/benefits discussed/handouts given

Done by: Lab Data: Last PPD:

Result: Labs/Screening tests:

Done by:

Next Resident Group Practice Visit:___________________________________

Provider Signature______________________________DATE___________________Provider Code______________

Attending Note:

Attending Signature__________________________________________DATE___________MD Code______________