ࡱ> kmj_ .bjbj nbb$w&&DTTTT\TT>TTTTTs$s$s$=======$j@Cf=s$S" s$s$s$=TT >&&&s$TT=&s$=&&;X{=T1%/<=$>0T>E<6C&(C,{={=C=0s$s$&s$s$s$s$s$==&s$s$s$T>s$s$s$s$Cs$s$s$s$s$s$s$s$s$& F:  Well-child Exam: 11-14 years CGs name: Kevin Marks MD, 2012; Last Revised 2-22-2012  ( Mom (Grandparent Who is at the WCV? ( Dad ( Foster parent Health, growth concerns? ( Sibling(s) ( Other Caregiver 1. ______________________________ 2. 3. _____________________ ( Teen & parent intake forms ( Sports pre-participation form Menarche: Age Regularity  5-2-1-0 & HEADS on back 5: Fruits & Veggies: 5 servings / day? ( Yes ( No 2: Less than 2 hrs of screen time/ day? ( Yes ( No 1: Activity/ exercise >1 hr/ day ( Yes ( No 0: Zero servings per day of sweetened drinks? ( Yes ( No Dairy or calcium-rich foods: 800 mg day? ( Yes ( No Foods high in sugar, trans & saturated fats? ( Yes ( No Elimination concerns? _______________________________  *See HEADS on back Concerns? Mental health & substance abuse screening (per AAP) Administered: ( PSC or Y-PSC circle if: ( - ) or ( + ) (+) Subscales: ( Internaliz. ( Externaliz. ( Attention Administered: ( CRAFFT circle if: ( - ) or ( + ) see back  Brushing 2x daily ( Flossing ( Fluoride rinse Dentist ( referred ( has seen_________________________  BEARS  Updated in Problem List / EMR  __________________________________________________ *See teen & parent intake forms + HEADS on back side  ( Lipid screening as indicated ( GlycoHgb A1C and OGTT as indicated ( Hemogram or HemaCue as indicated (after puberty) ( Urine Chlamydia TMA if sexually active  Vision: R _ _ / ____ ( Pass ( Refer L / _____ ( Evaluated by optometrist Bilat. __/ _____ or ophthalm. in last _____ mo Hearing: (only needed if (+) risk per AAP) ( Pass ( Refer R ____ @ ____ db L ____ @ ____ db (pure tone audiometry, 500 to 4000 Hz)  Vitals & Growth Parameters T (C/(F ax/rect/tymp P R BMI _ % Ht cm ( ____ %) Wt kg ( _____ %) BP / __ 90th%tile: M 113-120/ 74-75 F 114-119/ 74-77 GEN HEENT Chest/SMR Lungs CV/Heart ABD GU/SMR Skin MSK/Spine Neuro Behavior & hygiene__________________________________ Parent-Child Interaction Other_____________________________________________  Growth: ( typical ( obese ( overweight ( underweight/ FTT Development & Behavior: see above Other: see EMR problem list  __________________________________________________ 11-14 yr WCV handout (Bright Futures: Early Adolescence) ( Healthy Habits / obesity prevention handout + counseling ( AAP Calcium and You handout + MTV w/ iron & Vitamin D ( AAP Tips for Parents of Adolescents ( AAP The Internet & Your Family handout ( Mental health referral ( Tobacco/ drug/ alcohol/ substance abuse referral ( Actively suicidal/ emergency  Puberty & sexuality: get accurate info from a trusted adult or clinician; youth go through puberty at different times 5 servings daily of fruits/veggies, whole grain, low-fat dairy; limit candy/chips/soda; physical activity 60 min/day Limit media: TV, video games, internet use, cell phone use Clearly communicate rules/ family responsibilities Parents should get to know their childs friends Independently taking responsibility for schoolwork Talk about tobacco/ alcohol/ drugs/ inhalants/ sex Plan for situation where child feels unsafe riding in car  Refer to EMR for vaccines administered, CDC handouts given ( Vaccine counseling ( Refusal to vaccinate AAP form signed  ( Next routine well-child visit ( Early return OV HEEADSSS and CRAFFT Questionnaire or Interview for Adolescents HOME Do you think that your parent(s) or guardian(s) listen to you and take your feelings seriously? ( No ( Yes Are you permitted in your home to make independent decisions? ( No ( Yes Has you or anyone in your family ever been in counseling or had a mental health problem? ( No ( Yes Do you ever have family conversations at the table about how to cope with stress? ( No ( Yes Does anyone in your household smoke (including smoking outside)? ( No ( Yes How many guns are in your home? ( None ( >1 If >1, do you know how get to the gun and its ammunition? ( No ( Yes Who do you talk to when things are not going well? ______________________________________________________________ EDUCATION School_____________________________________________________________________Grade __________________ Are you eligible for special education services? ( No ( Yes Have an IEP or 504 behavioral plan? ( No ( Yes Any academic or homework concerns? ________________________________ Have you ever skipped classes or missed school? ( No ( Yes Is anybody concerned about your behavior or attention span? ____________-__ _____________________________ EATING Eating disorder Screen for Primary care (ESP), >2 (+) items in bold = (+) screen 1) Are you satisfied with your eating patterns? ( No ( Yes 2) Do you ever eat in secret? ( No ( Yes 3) Does your weight affect the way you feel about yourself? ( No ( Yes 4) Have any members of your family suffered with an eating disorder? ( No ( Yes 5) Do you currently suffer with or have you ever in the past suffered with an eating disorder? ( No ( Yes ACTIVITIES Getting at least 1 hour of physical activity per day? ( No ( Yes Screen time (except for homework) less than 2 hours per day? ( No ( Yes Have friends, interests or participating in community activities? ( No ( Yes Any parental concerns about internet safety? ( No ( Yes DRUGS: After first assuring confidentiality (with the parents outside the exam room) Do you currently smoke cigarettes? ( No ( Yes If yes, how many cigarettes do you smoke per day? ________packs per day Substance abuse screening (CRAFFT = questions 4 9) 1. Drink any alcohol (more than a few sips). Do not count religious or family events. ( No ( Yes 2. Smoke any marijuana or hashish? ( No ( Yes 3. Use anything else to get high? (illegal drugs, OTC or prescription drugs, things that you sniff or huff) ( No ( Yes 4. Ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? ( No ( Yes Then if no to ALL then STOP. If yes to ANY then ask: 5. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? ( No ( Yes 6. Do you ever use alcohol/drugs while you are by yourself, ALONE? ( No ( Yes 7. Do you ever FORGET things you did while using alcohol or drugs? ( No ( Yes 8. Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? ( No ( Yes 9. Have you gotten into TROUBLE while you were using alcohol or drugs? ( No ( Yes Then Score 1 for every yes for questions 4 9 and note that a score of 2 or more suggests a significant problem ( CRAFFT score 0 or 1 ( brief advice ( No signs of acute danger or addiction ( Brief negotiated interview to stop ( CRAFFT >2 ( brief assessment ( ( Signs of addiction / CRAFFT >5 / daily or near daily use ( Refer to treatment ( Signs of acute danger ( Make immediate intervention & contract for safety SAFETY Do you feel you live in a safe place? ( No ( Yes _________________________________________________________ In the past year, have you ever felt threatened in your home or a relationship? ( No ( Yes How often do you use a seatbelt? ( Never ( Rarely ( Sometimes ( Often ( Always Any history of impaired (e.g. alcohol, marijuana, etc.) or distracted driving (e.g. texting or talking on phone) ? ( No ( Yes SEX Are you attracted to (circle answer): males, females, both, not sure Are any of your friends sexually active? ( No ( Yes Have you ever had any sexual experiences? (circle if: oral, vaginal, anal) ( No ( Yes SUICIDALITY/ Mental health (PSC or Y-PSC) screening (Note: scoring is on the PSC or Y-PSC questionnaire) PSC or Y-PSC score:_____ ( ( - ) ( ( + ) (+) Subscales: ( Internalization ( Externalization ( Attention Do you ever see or hear things that arent there? ( No ( Yes Suicide-specific screening >1 (+) items are in bold = (+) screen 1) During the past 3 months, have you thought of killing yourself? ( No ( Yes 2) Have you ever tried to kill yourself? 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