Pediatric Endocrinology New Patient Consultation Note

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

Age: [Age in years and months]

Encounter Type: [new patient consult; in-person / telehealth (audio-video / audio-only)]

Accompanying Person: [Name and relationship / None]

History Source: [patient / parent-guardian / outside records] [Interpreter used: language, modality / No interpreter]

Referring Clinician: [Name, credentials, practice]

Reason for Consultation

[Primary referral question in one sentence, quoting or paraphrasing the referral when possible] [Secondary concerns if present, ranked by priority] [Urgency flags if applicable: rapidly progressive puberty, severe growth deceleration, symptomatic thyroid disease] (If referral documentation unavailable, state this and document caregiver-reported reason.)

Chief Complaint

"[Chief complaint in patient or caregiver words]"

History of Present Illness

[Problem identification, onset, and trajectory] (Format as 1–3 short paragraphs. Include onset, pace of change, associated symptoms, prior evaluation and treatment, and patient/family goals. Tailor content to the referral question using relevant modules below.)

[Associated symptoms, modifiers, and prior workup]

[Patient and family goals for today's visit]

(Include only the modules relevant to the referral question, integrated into the paragraphs above:)

• Growth-focused: [Onset] [Interval growth pattern and percentile crossing] [Nutrition] [Chronic disease symptoms] [Medication exposures: glucocorticoids, stimulants]
• Puberty-focused: [First pubertal sign and age] [Tempo of progression] [Neurologic symptoms] [Psychosocial impact] [Exogenous hormone exposures]
• Thyroid-focused: [Why labs were obtained] [Pattern of abnormality] [Hypo/hyperthyroid symptoms] [Neck symptoms] [Interfering medications or supplements]
• Obesity/weight-focused: [Weight trajectory] [Appetite and activity patterns] [Sleep and snoring] [Comorbidity symptoms] [Prior interventions] [Patient-centered goals]

Records Reviewed

(Explicitly differentiate between records reviewed directly, information reported by family, and records requested but not yet received.)

• [Referral note: date, source] — [Reviewed directly / Not available]
• [Growth charts from PCP: date range] — [Reviewed directly / Reported by family]
• [Prior endocrine notes: dates] — [Reviewed directly]
• [Laboratory results: test names, dates] — [Reviewed directly]
• [Imaging reports: study, date] — [Reviewed directly]
• [Information reported by family but not verified] (Label clearly as reported.)
• [Records requested but not yet received: source, date requested]

Past History

• Birth/perinatal: [Gestational age] [Birth weight/length] [Complications] [Newborn screen results if relevant]
• Past medical/surgical: [Chronic illnesses] [Prior fractures] [Malabsorption/GI disease] [Neurologic disease] [Relevant surgeries]
• Medications and supplements: [List with dose/frequency] (Note endocrine-active agents: steroids, stimulants, antiepileptics, psychotropics, hormones.)
• Allergies: [Drug/food/environmental with reaction type]
• Developmental: [Milestones/concerns] (Include only if relevant to suspected syndromic or neuroendocrine conditions.)

Family History

• Parental heights: Mother [height, measured / reported]; Father [height, measured / reported]
• Parental puberty timing: Mother menarche age [age]; Father growth spurt timing [early / average / late / unknown]
• Siblings: [Heights and pubertal timing if known]
• Endocrine/autoimmune conditions: [Thyroid disease, type 1 diabetes, celiac disease, adrenal disease, pituitary tumors, other]
• Genetic syndromes/consanguinity: [Present / Absent / Unknown]
• (If family history limited by adoption or other factors, state this.)

Social History

• Household: [Composition]
• School: [Grade level]
• Activity: [Physical activity level]
• Diet: [Food environment and meal patterns]
• Sleep: [Schedule and quality]
• Adolescent confidentiality: [Time alone with patient: yes / no] [Domains reviewed in general terms] (Include for adolescents only.)

Review of Systems

(Document only systems actually reviewed; do not auto-populate negatives.)

• General: [Energy, appetite, weight change]
• GI: [Stooling pattern, abdominal pain]
• Neuro: [Headache, vision changes]
• Cardiac: [Palpitations, exercise intolerance]
• Skin: [Acanthosis, striae, hirsutism, acne, vitiligo]
• GU/Puberty: [Bleeding, discharge, testicular pain, gynecomastia]
• Sleep: [Snoring, restless sleep]
• Mood: [Irritability, anxiety, depression] (Include if relevant.)

Objective

Vitals and Anthropometrics

• Measurement method: [Stadiometer, shoes off / Reported by caregiver / Telehealth self-report]
• Height: [cm] ([percentile], z-score [value])
• Weight: [kg] ([percentile], z-score [value])
• BMI: [kg/m²] ([percentile], z-score [value])
• Blood pressure: [mmHg] ([percentile per age/sex/height])
• Heart rate: [bpm]

Growth Chart Review

[Current height/weight/BMI percentiles and z-scores] [Trend: stable channel / crossing percentiles—direction] [Growth velocity: cm/year over interval, source dates] [Midparental target height: value, based on mother height and father height (measured / reported)] (If data insufficient to assess velocity, state this and document the plan to obtain records.)

Physical Examination

• General: [Appearance, body habitus, dysmorphic features]
• HEENT: [Pupils, EOM, visual fields if indicated]
• Neck/Thyroid: [Size, texture, tenderness, nodules, lymphadenopathy]
• Cardiovascular: [Rate, rhythm, murmur]
• Abdomen: [Hepatosplenomegaly, tenderness, striae]
• Skin: [Acanthosis, striae, café-au-lait spots, vitiligo, hirsutism, acne]
• MSK: [Proportions, scoliosis, gait]
• Neuro: [Tone, strength, reflexes]

Pubertal Staging

(Include only when puberty-related exam is performed or staging is clinically relevant. Do not infer staging from history alone without stating source.)

• Exam status: [Performed / Deferred—reason: patient declined / not clinically indicated / telehealth]
• Consent and chaperone: [Exam explained and assent/consent obtained; Chaperone: name and role / Chaperone offered and declined]
• Female: Breast Tanner [stage], Pubic hair Tanner [stage]; Menarche [age / not yet]; Cycles [regular / irregular / N/A]
• Male: Genital Tanner [stage], Pubic hair Tanner [stage]; Testicular volume [mL, method: orchidometer / ultrasound]
• (If based on history only, state: Staging per caregiver/patient report; exam not performed.)

Labs and Imaging Reviewed

(Present results reviewed today in table format. Clearly separate from tests ordered today. Include only categories relevant to the clinical question.)

Results Reviewed Today

Test	Date	Value	Reference Range	Interpretation
[Test name]	[Date]	[Value with units]	[Range]	[Interpretation]

Bone Age

Date	Bone Age	Chronological Age	Interpretation Source	Notes
[Date]	[years/months]	[years/months]	[Radiology report / Independent review]	[Delayed / Concordant / Advanced]

Other Imaging

Study	Date	Key Findings	Impression
[Thyroid ultrasound / Brain MRI / Pelvic ultrasound / Other]	[Date]	[Findings]	[Impression]

Tests Ordered Today

Test/Study	Indication	Timing/Conditions
[Test name]	[Clinical question]	[Fasting / Morning / Random; special instructions]

Assessment

Summary: [Age]-year-old [sex] referred for [referral question]. [Key auxology: height percentile, growth velocity, bone age]. [Pubertal context if relevant]. [Salient positives and negatives]. [Leading diagnostic considerations].

Problem List: (In order of clinical priority.)

• Problem 1: [Working diagnosis or differential] — [Rationale tied to clinical data; severity/progression; diagnostic uncertainty if applicable]
• Problem 2: [Diagnosis] — [Rationale] (Add additional problems as needed.)

Plan

(Organize by problem. If plan cannot be finalized due to missing data, state this and provide provisional plan.)

Problem 1: [Diagnosis]

• Diagnostics: [Labs with timing/conditions] [Imaging with indication] [Records to obtain]
• Therapeutics: [Medications with dose/route/monitoring] [Non-pharmacologic interventions]
• Counseling: [Key discussions, risks/benefits, patient/family goals and agreement]
• Referrals: [Dietitian, behavioral health, genetics, other]
• Follow-up: [Interval] [Data needed before next visit] [Return precautions]

Problem 2: [Diagnosis] (Repeat structure as needed.)

Communication to Referring Clinician

[Brief summary of impression and planned workup] [Follow-up timing] [Specific requests to referring provider: growth charts, prior labs, other] (If summary letter will follow pending results, note this.)