By Robert W. Blum (Eds.)
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Extra info for Adolescent Health Care. Clinical Issues
How old are they? : 43. Who lives at home with you? (for example, brothers, sisters, parents, grandparents, friends, others)_ 44. While we're on the subject of family, what would you like to change about your family? 45. What would you like to keep the same? 46. What kinds of things do you and your family argue about the most? Figure 1 (continued) 38 47. Do you feel you are physically mistreated (hit or beaten) by a member of your family? 48. Is this something you would like to talk about with someone at the clinic?
4. The Comprehensive Health History and Physical Examination Date 41 ______ Chart # COMPLETE PHYSICAL EXAMINATION FORM FOR TEENS BP P Ht Wt L Vision (Snellen's): Without glasses ________ With glasses Respiration^ Temp R ___ ________ Personality (please describe): Summary of presenting problem and other concerns expressed by patient: PHYSICAL EXAM Body Part Review of Systems Normal ABNORMAL FINDING (please indicate which or explain) Skin Acne, color, scars or marks, pigmentation, rash, other Ears Hearing, external otiti s, otiti s media, other Eyes Exopathalmos, unequal pupils, nystagmus, fundi, other Nose Obstruction, polyps, sinus tenderness, other Mouth and throat Caries, occlusion, gums, tonsils, other Neck Thyroid, lymoh nodes, masses, cysts, other Chest, breasts, and lungs Deformity, qynecomastia (m), breast development (f), cyst/nodule, tenderness, other Cardiovascular BP, murmur, pulses (femoral), rubs, other Figure 2 Complete physical examination form for teens.
PAST HEALTH HISTORY 49. Have you ever: a. Stayed overnight in the hospital? no yes For what? b. Had an operation or abortion? no yes What kind? c. Had any serious injuries (concussions, broken bones, etc)? What kind? yes no no When? When? no yes When? 50. As you were growing up, you probably had some childhood diseases or possibly other problems. Please check those that you remember having had (or now have). measles vaginal or pelvic infections mumps dizzy spells chicken pox breathing problems German measles (rubella) bladder or kidney problems (urine infections) rheumatic fever heart problems or high blood pressure diabetes stomach problems.