Well Child Check - 13 to 17 Years
Patient’s name:______________________________________ DOB:______________
Reason for visit: O Well child check O GI issues O Sick/fever O Other: __________________
Up to date on immunizations? O Yes O No O Own schedule Past reactions?
O Yes O No
Diet from all the food groups to include: O Milk/Dairy O Meat O Grains O Vegetables O Fruits
Do you have regular dental check-ups every 6 months? O Yes O No O Once a Year
Grade in school? __________ Grades: O A-B O B-C O C-D O D-F O N/A
Have you had to repeat a grade? O Yes O No
Where do you go after school? O Home O Relative O After school activity O Other: __________
Do you play any sports/activities? O Yes: _____________ O No
How many hours of exercise do you get daily? O None O 1 O 2 O 3 O 4 O 5+
Do you have friends? O Some O Lots Do you get along with your siblings? O Yes
Do you get along with your parents? O Yes O No
How many hours of TV, computer, texting time daily? O None O 1 O 2 O 3 O 4 O 5+
What are your favorite things to do? ___________________________________________
Are there guns in the home? O No
Do you wear Seat Belts in the car? O Yes
O Yes: In a safe? O Yes O No
O No
O No
Do you wear a bike helmet/safety gear? O Yes O No
Do you drive? O Yes (license) O Yes (permit)
Exposed to second-hand smoke? O Yes O No
O No
Current Medication(s), including vitamins, supplements/herbs: dose and quantity:
O Multivitamin O Fluoride O Other: ___________________________
Allergies __________________ Reaction: _______________________
YOUR Medical History: Current and/or have a history of:
O Heart Disease O Hypertension O Diabetes O Cancer O Asthma O Psychiatric disorder
O Depression O Anxiety O Stroke O Bleeding disorder O Thyroid disease O Kidney disease O High cholesterol O Alcohol abuse O Substance abuse O Bowel disorders
O Urinary problems O Others:
Surgical History and dates:
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Hospitalizations and dates:
Family History:
Year of Birth
Alive
Deceased
High cholesterol
Heart disease
Hypertension
Father Mother Sibling(s) Children Extended Family
Diabetes
Cancer
Stroke
Thyroid disease
Kidney disease
Bleeding disorder
Substance abuse
Depression
Psychiatric disorder
Other
Father , stepFather, or legal guardian’s name: ____________________________________
Mother, step-
Mother, or legal guardian’s name: __________________________________
Siblings name(s) and ages: ________________________________________________________
Who lives in your home , besides parents and siblings? O Grandparents O Other relatives
O Friends
Childhood Illnesses:
O Measles (14-day Rubeola) O Frequent colds O Pneumonia O Mumps O Strep throat
O Tonsillitis O Rubella (3-day German measles) O Scarlet Fever O Ear Infections
O Chickenpox O Fever O Diabetes O Skin rashes O Herpes
Immunizations:
O MMR (measles, mumps, rubella) O Chickenpox O Influenza (flu) O DPT (diptheria, pertussis, tetanus) O Tetanus O Hepatitis O Polio O Others (please list)
Social/Habit History:
Travel outside US?: O NO O Yes = where? ______________
Do you use a smoke detector in your home?: O No O Yes
Do you have pets?: O No O Yes
GYN History: Age period started: _________ Date of last Menstrual period: ___/___/_____
Problems with: O cramps O irregular O heavy bleeding O hot flashes O vaginal dryness
O vaginal discharge O vaginal infections O incontinence
What do you use for birth control: O Nothing O Permanent Sterilization (vasectomy/tubal ligation)
O Birth control pills O Condom O Nuvo-ring O IUD (Mirena/Paraguard) O Other
OB History: Pregnancies: __ Living children: __
Still births: __ Miscarriages: __ Abortions:__ C-sections: __
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Review of Systems
Constitutional: O None of the following O fever O weight loss O weight gain O fatigue
O loss of appetite O night sweats
Cardiology: O None of the following O chest pain with exertion O dizziness O palpitations
O feet or hand swelling
Dermatology: O None of the following O rash O hair loss O skin changes O moles O sores
Endocrinology: O None of the following O excessive urination O excessive thirst
O excessive hunger O heat/cold intolerance O hair loss O hot flashes
Gastroenterology: O None of the following O nausea O vomiting O diarrhea O constipation
O blood in stool O difficulty swallowing
Hematology: O None of the following O easy bruising O bleeding gums O enlarged lymph gland
Musculoskeletal : O None of the following O joint pain O muscle pain O muscle weakness
Neurology: O None of the following O headache O numbness in hands or feet
O tingling in hands or feet O fainting O seizures O trouble walking
Ophthalmology: O None of the following O visual changes
Psychology: O None of the following O depression O anxiety O insomnia O crying
O panic attacks
Respiratory: O None of the following O shortness of breath O cough O congestion
O chest pain with breathing
Urology: O None of the following O painful urination O frequency O urgency O blood in urine
O incontinence O incomplete emptying
Infectious Disease: O None of the following O fever O nausea O vomiting O sick contacts
Breast: O None of the following O nipple discharge O pain in breasts O masses
For males only :
Male reproductive: O None of the following O frequent voiding at night O slow stream
O difficulty with erection O diminished sex drive O penile discharge
For females only:
Female reproductive: O None of the following O difficult or painful sex O painful periods
O bleeding after sex O irregular bleeding
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