Adolescent Preventive Visit Note

Date: [visit date]   Patient: [name, age, pronouns if provided]   Provider: [rendering clinician]

Present: [who attended the visit and who provided history; note if patient interviewed alone]

Confidentiality

[Private time completed / Private time offered; not completed—[brief reason] / Private time not offered—[brief reason]]. Confidentiality and limits (harm to self/others, abuse/neglect, mandatory reporting) [discussed / not discussed—[brief reason]].

History

[Interval health changes since last visit, including illnesses, injuries, ER/urgent care visits, hospitalizations, chronic condition updates. Note current medications, adherence, and allergies with reactions. Attribute source: parent / adolescent / both.]

[Functional domains: school performance and attendance, sleep, nutrition, physical activity, dental care. Attribute source.]

[Family history updates, with emphasis on early cardiac disease or sudden death if sports clearance requested. If none: "no updates reported" or "not obtained—[reason]."]

Screening Summary

(For each domain: document tool used, result/score, interpretation, and action taken. If not completed, document "not obtained—[reason]." Do not infer negative results for domains not assessed.)

• Mental Health: [Depression tool]: [score]; Suicidality item: [denied / endorsed]; Interpretation: [negative / positive / elevated risk]. [Anxiety tool if performed]: [score, interpretation]. Action: [counseling / safety plan / referral / crisis protocol / none indicated]. (If suicidality endorsed: document immediate safety assessment, risk stratification, means restriction discussion, and disposition.)
• Substance Use: [Tool]: [result/score]; Interpretation: [negative / risky use / disorder risk]. Completed privately: [yes / no—reason]. Action: [prevention counseling / brief intervention / referral / none indicated].
• Sexual/Reproductive Health: Sexual activity (patient-reported): [not active / active / not obtained—[reason]]. [If active: risk factors, partner info, barrier use as relevant.] STI/HIV screening: [offered and accepted / offered and declined / deferred—[reason]]. Contraception: [method in use / options reviewed / not applicable]. Menstrual history (if relevant): LMP [date]; cycle [regular / irregular]; [symptoms if applicable]. (Document with awareness of confidentiality per institutional policy.)
• Safety: [Key domains assessed: driving/seatbelts, helmets, firearms access/storage, violence exposure/bullying, online safety. Summarize findings and counseling provided. For athletes: concussion history and exertional symptoms (chest pain, syncope, palpitations, dyspnea). Document "not obtained—[reason]" for any domain not assessed.]

Exam

Vitals: Height [value, percentile]; Weight [value, percentile]; BMI [value, percentile]; BP [value]—[normal for age/sex/height / elevated / Stage 1 / Stage 2]

Exam: [Pertinent findings by system; document normal findings briefly, expand on abnormalities]

Tanner staging: [stage / deferred / declined]

Chaperone: [offered and present / offered and declined / not applicable] (Document if breast, genital, or rectal exam performed.)

POC tests: [test name(s) and result(s) / none]

Assessment and Plan

(Use problem-list format. If information is missing or deferred, state "not obtained—[reason]" or "deferred to follow-up.")

Health Maintenance / Preventive Care

[Overall health status, growth interpretation (BMI percentile context, BP category), and summary of screening outcomes with identified risks]

• Immunizations: [reviewed and up to date / due—administered today (VIS provided) / deferred—[reason] / declined—[reason]]
• Counseling: [tailored topics addressed with brief personalization: nutrition, activity, sleep, mental health, sexual health, substance prevention, safety]
• Referrals/Follow-up: [behavioral health, dental, vision, specialty, community resources as indicated]; [lab/imaging orders and result routing]; [next routine visit timing]
• Sports Clearance (if applicable): [Cleared without restriction / Cleared with recommendations—[specify] / Not cleared pending evaluation—[specify]]. Forms completed: [yes / no]. [Return-to-play guidance if relevant.]

[Additional Problem]: [Diagnosis or concern]

[Brief assessment summarizing key findings]

• Plan: [interventions, medications with doses if applicable, labs/imaging, education, follow-up, referrals]

(Add additional problems as needed using the same structure.)