ADOLESCENT HISTORY AND PHYSICAL EXAMINATION FORM

History and Physical Examination in Adolescents

January 17, 2021

ADOLESCENT HISTORY
I. Personal Data
A. Name of Patient
B. Sex
C. Age
D. Date of Birth
E. Contact Numbers
F. City Address
G. Provincial Address
H. Parent / Guardian’s Name
I. Parent / Guardian’s Address

II. History
A. Informant
B. Chief Complaint
C. History of Present Illness

III. Review of Systems

A. Central Nervous System
1. Headache
2. Dizziness
3. Convulsions
4. Fainting
B. Skin
1. Acne
2. Warts
3. Rashes
C. Vision
1. Trouble reading
2. Watching TV
3. Glasses
D. Hearing
1. Trouble hearing
2. Earaches
3. Discharge
E. Nose / Throat
1. Frequent colds
2. Frequent sore throat
F. Neck
1. Masses
2. Stiff muscles
3. Draining sinus
 G. Dental
1. Caries
2. Pain
3. Concerns (braces)
H. Respiratory
1. Cough
2. Difficulty breathing
I. Cardiovascular System
1. Chest pain
2. Palpitations
3. Easy fatigability
J. Gastrointestinal Tract
1. Pain
2. Diarrhea
3. Constipation
4. Vomiting
5. Jaundice
K. Genitourinary Tract
1. Dysuria
2. Frequency
3. Bleeding
4. Incontinence
L. Musculoskeletal
1. Joint pains
2. Swelling
3. Muscle pains

IV. Past Medical History

A. Infections and Illnesses
B. Hospitalization and Surgery
C. Injuries and Disabilities
D. Medications
E. Allergies

V. Ancillary History
A. Immunization History
1. BCG
2. Hepatitis B
3. OPV
4. DPT
5. HiB
6. Measles
7. PCV
8. Rotavirus
9. Tdap
10. TT
 11. Varicella
12. MMR
13. Hepatitis A
14. Typhoid
15. Influenza
B. Nutritional History
C. Developmental History
1. No concerns
2. With concerns regarding any of the following:
i. Motor
ii. Language
iii. Socialization
iv. Adaptive behaviors

VI. Family History

A. Age and Health Status of Family Members
B. History of Significant Illnesses
1. Diabetes
2. Hypertension
3. Cardiac death <55 years old
4. Stroke
5. Cancer
6. Tuberculosis
7. Asthma
C. History of Mental Illnesses

VII. Gynecologic History

A. Age of Menarche
B. Last Menstrual Period
C. Cycle Length
D. Duration
E. Menstrual Flow
F. Dysmenorrhea
1. Timing
2. Severity
3. Interferes with activities?
4. Medications taken
G. Pain or bleeding between periods?
H. Vaginal discharge?
I. Pregnancies?
J. Abortions?

VIII. Psychosocial History

A. Home
1. Who lives with you?
2. Where do you live?
 3. What are relationships like at home?
4. How are relationships between you and parents? Siblings? Between
parents?
5. To whom are you closest to?
6. Are there any recent changes in the living arrangement?
B. Education / Employment
1. Are you currently in school? Out of school? Employed?
2. Where?
3. Tell me about school.
i. What do you like about it?
ii. What don’t you like about it?
iii. Average last grading / semester?
iv. How are your relationships with classmates and teachers?
v. Ever been truant / suspended / expelled from school?
4. What are your future education / employment goals?
5. Ever experienced bullying? Is it still a problem?
C. Eating
1. How would you describe your eating habits?
i. Dieting?
ii. Skipping meals?
2. Food preferences? Commented [JDT1]: Dr. Natasha Ann Esteban-Ipac
D. Activities
1. What do you and your friends do for fun? Commented [JDT2]: Dr. Natasha Ann Esteban-Ipac
2. What are your hobbies / interests / sports?
3. How do you spend time with friends? Family?
4. What type of things do you use the internet for?
5. What sites do you visit?
6. How many hours do you spend daily in front of the screen?
E. Drugs
1. Do any of your friends or family members use tobacco? Alcohol? Other
drugs?
2. Do you use tobacco? E-cigarettes? Vaping? Alcohol? Other drugs?
Energy drinks? Steroids? Or medications nor prescribed to you?
3. Assess:
i. Frequency
ii. Intensity
iii. Patterns of use
iv. How patient obtains drugs, alcohol, tobacco
4. CRAFFT Commented [JDT3]: Dr. Natasha Ann Esteban-Ipac
 i. Car - Have you ever ridden in a CAR driven by someone
(including yourself) who was "high" or had been using alcohol or
drugs?
ii. Relax - Do you ever use alcohol or drugs to RELAX, feel better
about yourself, or fit in?
iii. Alone - Do you ever use alcohol/drugs while you are by yourself,
ALONE?
iv. Forget - Do you ever FORGET things you did while using alcohol
or drugs?
v. Family & Friends - Do your FAMILY or FRIENDS ever tell you
that you should cut down on your drinking or drug use?
vi. Trouble - Have you gotten into TROUBLE while you were using
alcohol or drugs?
Each “Yes” = 1 point
Positive Screen ≥2 points

F. Sexuality / Sexual Activity

1. Younger teen: Tell me about any of your friends who are starting to be in
romantic relationships
2. Older teen: Tell me about any romantic relationships you have
3. been involved in. Commented [JDT4]: Dr. Natasha Ann Esteban-Ipac
4. Do you have any questions regarding changes in your body?
5. Have you ever been in a romantic relationship?
6. If none, are you attracted to anyone right now? Boys? Girls? Or both?
7. If yes, can you tell me about the people you have dated?
8. Have any of your relationships become sexual?
9. Age of sexual debut?
10. 5P’s
i. Partners:
a. Number
 b. Sex
c. Age
ii. Pregnancy or Paternity
iii. Protection against STI / HIV
a. If none, explore reason why
iv. Practices (sexual)
v. Past History of STIs
11. Have you ever felt pressured or coerced into having sex?
G. Suicide / Depression
1. What stresses you?
2. Do you feel “stressed” or anxious more than usual?
3. Do you feel sad or down more than usual?
4. Does it seem that you have lost interest in things that you used to really
enjoy?
5. Have you ever thought about hurting yourself or someone else?
6. If yes, have you ever hurt yourself to calm down or feel better?
7. Have you ever tried to kill yourself?
i. PHQ-9 → depression

Cut-off Score ≥3

a. Over the past two weeks, how often have you been
bothered by any of the following problems?
i. Little interest or pleasure in doing things
ii. Feeling down, depressed, or hopeless
iii. Trouble falling or staying asleep, or sleeping too
much
iv. Feeling tired or having little energy
v. Poor appetite or overeating
vi. Feeling bad about yourself or that you are a failure
or have let yourself or your family down
vii. Trouble concentrating on things, such as reading the
newspaper or watching television
viii. Moving or speaking so slowly that other people
could have noticed. Or the opposite - being so
fidgety or restless that you have been moving
around a lot more than usual
 ix. Thoughts that you would be better off dead, or of
hurting yourself in some way
b. Scoring:
Score Severity
0–4 No to Minimal Depression
5–9 Mild Depression
10 – 14 Moderate Depression
15 – 19 Moderately Severe
Depression
20 – 27 Severe Depression

ii. CSSR-S → suicidality

H. Safety
1. Have you ever had a serious injury?
2. Is there violence in school, neighborhood, friends, family? Commented [JDT5]: Dr. Natasha Ann Esteban-Ipac
3. Have you ever experienced cyberbullying and how did you deal with it?
 4. Do you have online friends and chat mates that you have never met?
5. Have you ever met in person or plan to meet with anyone whom you
encountered online?
6. Do you use a seatbelt / helmet?
7. Ever drove when drunk or been in a vehicle driven by someone who was
drunk / high?
8. Are you a member of a fraternity / sorority or gang?
9. Do you carry a weapon for protection?
10. Is there a firearm in your home?
I. Spirituality
1. How do you cope with stress / difficult times?
2. Do you have spiritual beliefs that help you cope?
3. Are you part of a spiritual community?

PHYSICAL EXAMINATION
I. Vital Signs
A. Heart Rate
1. 10-14 years old: 55 – 115 bpm
2. ≥15 years old: 60 – 100 bpm
B. Respiratory Rate (12 – 20 breaths / minute)
C. Blood Pressure
II. Anthropometrics
A. Weight
B. Height
C. BMI
D. Z Score
III. Survey
A. General Survey
 B. Skin
1. Tattoos
2. Piercings
3. Acne
C. Head
D. Eyes
E. Ears
F. Nose
G. Teeth, Gums, Tonsils
H. Thyroid, Lymph Nodes
I. Chest and Lungs
J. Breast
1. Gynecomastia
K. Heart
L. Abdomen
M. Musculoskeletal
1. Scoliosis
N. Female Genitalia
1. Warts
2. Vesicles
3. Discharges
4. Anomalies
O. Male Genitalia
1. Warts
2. Vesicles
3. Discharges
4. Testicles
5. Hernia
6. Varicocele
7. Masses
P. Neurologic
1. Mental Status
2. Motor
3. Sensory
4. Cerebellar
5. Reflexes
6. Cranial Nerves
IV. Sexual Maturity Rating
A. Male
1. Pubic Hair
2. Genitalia
B. Female
1. Pubic Hair
2. Breast