January 2010




ACOG Adolescent Visit Record and ACOG Adolescent Visit and Parent Questionnaires

Physicians should develop office procedures that safeguard their adolescent patients’ rights. These procedures will vary by practice, staff capabilities, and facilities. An initial and annual
office visit process is described that works well with the ACOG Adolescent Visit Questionnaire, ACOG Parent Questionnaire, and ACOG Adolescent Visit Record, all of which can be adapted for an electronic medical record. These steps can be used for preventive visits in which the adolescent patient is accompanied by her parent or guardian but also could be used for problem visits.

ACOG Adolescent Visit Record and ACOG Adolescent Visit and Parent Questionnaires Tool Kit for Teen Care second edition Tool Kit for Teen Care, second edition Physicians should develop office procedures that safeguard their adolescent patients’ rights. These procedures will vary by practice, staff capabilities, and facilities. An initial and annual office visit process is described that works well with the ACOG Adolescent Visit Questionnaire, ACOG Parent Questionnaire, and ACOG Adolescent Visit Record, all of which can be adapted for an electronic medical record. These steps can be used for preventive visits in which the adolescent patient is accompanied by her parent or guardian but also could be used for problem visits. A progress notes page is included in the ACOG Adolescent Visit Record in case a repeat visit is scheduled. The progress notes page also can be used for subsequent annual visits. For these annual visits, the questionnaire should be completed again. There are many different ways to handle an adolescent preventive visit. Issues of confidentiality should be discussed at all visits. Please review this process and determine what will work best for your practice. For more information, refer to “Confidentiality in Adolescent Health Care.” 1. While in the waiting room, the parent or guardian, if present, is asked to complete the parent questionnaire. Note that the parent questionnaire is not meant to be comprehensive and will not capture the patient’s entire medical and family history. This form can be mailed to the parent ahead of time and brought with them to the visit. When the parent has completed the questionnaire, a nurse or nursing assistant can transfer the contact information, family history, and medications from questions 1–4 to sections I and II of the ACOG Adolescent Visit Record and any identified issues of concern from questions 5–9 to the shaded area of section IV of the ACOG Adolescent Visit Record. The strengths and talents identified in question 10 can be used to establish a connection or rapport with the patient by providing a way to personalize the visit. Based on the parent’s responses, a determination regarding the need for a confidential meeting with the parent is made. In particular, questions 11, 12, and 13 can be used to gain a better understanding of the patient–parent relationship, the significance of the parent’s concerns, or both. A meeting with the parent can be beneficial. Discussion topics may include normal adolescent development, the potential health risks facing his or her daughter, the benefits of participation in sports, parenting behaviors that support healthy and safe adolescent development, ways to minimize potentially harmful behaviors, and the influence of the media on adolescents. For more information, see “Primary and Preventive Health Care for Female Adolescents.” If a parent-only meeting is conducted, it is important that it be held before the visit with the patient to avoid the teen being concerned that confidentiality will be breached. It also is important to tell the teen that the parent visit is about to take place and then share the topics of the physician–parent conversation with the patient. 2. Structure of the visit is explained to the parent and adolescent patient. The physician, nurse, or nursing assistant initially sees the parent or guardian and the adolescent patient together to explain the structure of the visit. The issue of confidentiality also should be discussed at this time. 3. Reason for visit and patient history are assessed using sections I–II of the ACOG Adolescent Visit Record. (A nurse or nursing assistant, depending on staff capabilities and facilities, can complete these and all shaded areas of the record.) Contact information and information about sexual activity in section II should not be gathered in the presence of a parent or guardian. (See 5 and 8.) 4. Patient completes ACOG Adolescent Visit Questionnaire. The nursing assistant takes the parent to a separate room (waiting room or private hallway if a room is not available) so the patient can complete the questionnaire in privacy. Back in the examination room, the nursing assistant assures the patient that the form is confidential and will not be released without the teen’s permission except in life-threatening situations. To ensure confidentiality, some offices may wish to note on the ACOG Adolescent Visit Questionnaire that it will not be filed with the patient’s chart. That is, the questionnaire can be discarded after being summarized in the chart. The nursing assistant should be available to answer any questions the patient may have about the questionnaire. 5. Review of completed questionnaire. When the patient has completed the questionnaire, any identified issues of concern are transferred to the shaded area of section IV of the record. Special attention should be given to any topics identified by the patient in the last question or to any question left blank. Any question left blank should be asked of the patient. If she is concerned about this information being made available to her parent( s) or guardian(s), consider not including this material on her chart or developing a code for such information. Select questions regarding sexual activity are transferred to the nonshaded areas in section II. Again, depending on staff capabilities and facilities, a nurse or nursing assistant can review the complete questionnaire and transfer the information. Some patients are not comfortable answering certain questions in writing. Therefore, regardless of answers, it may be helpful to review questions with the patient to ensure receipt of accurate answers. If there is significant concern that the form will not be completed accurately, the nurse or nursing assistant may wish to complete the form with the patient face-to-face. 6. Parent returns to the examination room. The parent returns to the examination room where the patient is waiting. The shaded areas in section V of the ACOG Adolescent Visit Record and the ACOG Vaccine Administration Record are completed. The patient should be asked when the appointment is made to bring in their immunization record. Immunization status should be reviewed using the ACOG Vaccine Administration Record. 7. Confidential discussion with the patient. The parent or guardian should then be excused from the room. This allows for a confidential discussion between the physician and the patient about her health-related behaviors and concerns as sections III and IV of the ACOG Adolescent Visit Record are completed. Should a physical examination be necessary, the patient should be given a description of this process and asked if she would like a parent or other individual present. Section VI of the ACOG Adolescent Visit Record will guide this examination. 8. Diagnosis and treatment options are discussed. Consultation with the patient should address physical findings and diagnosis and treatment options, if needed. Sections VII and VIII of the ACOG Adolescent Visit Record can be completed at this time. In addition, a method for reporting confidential laboratory results to the adolescent should be established at this time and noted under “Contact Information” above section I of the ACOG Adolescent Visit Record. Once a mutually agreed-upon treatment plan is established, the adolescent is encouraged to include her parent in treatment planning. 9. Joint meeting with the patient and the parent. The patient, her parent, and the physician meet again to discuss findings and recommendations, if appropriate. Any remaining concerns also can be addressed. 10. Claim submission. Finally, a claim is filed. Hints have been added to help with coding and documentation of this visit. Hints marked as “FOR PROBLEM VISIT ONLY” do not apply when conducting a preventive visit. See Billing and Coding Issues in Adolescent Reproductive Health. Copyright © 2010, The American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920Washington, DC 20090-6920 (AA414) 12345/43210 Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 PARENT QUESTIONNAIRE Instructions: Thank you for taking the time to complete this questionnaire about your daughter. This information will be used to provide her with the best possible care. 1) Please let us know how to reach you in case we need additional information: Your name: __________________________________________________ E-mail: ________________________________________________________ Phone #1: (______) ____________________________________________ Phone #2: (______) ____________________________________________ 2) Please mark any conditions that run in your family (on the patient’s mother’s or father’s side).  High blood pressure  High cholesterol  Obesity  Diabetes mellitus  Heart disease  Death of a parent or grandparent from heart attack before age 55 years  Stroke  Death of a parent or grandparent from stroke before age 55 years  Peripheral vascular disease  Cerebrovascular disease  Asthma  Allergies  Cancer (breast, colon, ovarian, or uterine)  Seizures  Eating disorder  Anxiety  Depression  Bipolar disorder or other mental health issues  Excessive bleeding or clotting problems  Other (infertility, polycystic ovary syndrome, endometriosis, uterine leiomyomas, or genetic diseases) If other, please explain___________________________________________________________________________________________________________ 3) Has your daughter ever had surgery or been hospitalized?  Yes  No Please describe: __________________________________________________________________________________________________ 4) Please list all prescription and over-the-counter medications your daughter is taking, including any vitamins or supplements: ______________________________________________________________________________________________________________________________ 5) Do you have concerns about your daughter’s health or lifestyle?  Yes  No Please describe: __________________________________________________________________________________________________ Have you talked with her about your concerns?  Yes  No 6) Have there been any changes, health problems, or stresses in your family this past year?  Yes  No Please describe: __________________________________________________________________________________________________ 7) Have you noticed any changes in your daughter’s behavior, such as unusual anger or irritability, withdrawal, secrecy, sadness, depression, or problems at home or school?  Yes  No Please describe: __________________________________________________________________________________________________ 8) Do you think that smoking, drinking, or drug use is a problem for your daughter or anyone in your family?  Yes  No Please describe: __________________________________________________________________________________________________ 9) Is your daughter exposed to violence, such as hitting or fighting, in your home or community?  Yes  No Please describe: __________________________________________________________________________________________________ 10)What are your daughter’s strengths and talents? _______________________________________________________________________ 11)Would you like help talking with your daughter about sex, drinking, drugs, smoking, or other social issues?  Yes  No Please describe: __________________________________________________________________________________________________ 12) Is there anything you would like to discuss with the doctor or nurse today?  Yes  No Please describe: __________________________________________________________________________________________________ 13) Can we share your answers to any of the questions above with your daughter?  Yes  No Please explain: ___________________________________________________________________________________________________ Primary Care Physician: Name:____________________________________________________________Telephone #: ___________________________________________________ Who referred you? Name:____________________________________________________________Telephone #:____________________________________________________ List other doctors or mental health counselors your daughter has seen in the past year: Name:____________________________________________________________Telephone #:____________________________________________________ Name:____________________________________________________________ Telephone #: ___________________________________________________ ACOG ADOLESCENT VISIT QUESTIONNAIRE We strongly encourage you to discuss all issues of your life with your parent(s) or guardian(s). However, unless it is a life threatening issue, the information you give us on this form is CONFIDENTIAL between our doctors and nurses and you. It will not be released without your written consent. If you would like help filling out this form, please let the nurse know. IF YOU DO NOT FEEL COMFORTABLE ANSWERING A QUESTION, LEAVE IT BLANK AND YOUR DOCTOR OR NURSEWILL TALKWITH YOU ABOUT IT. Name: __________________________________________________________ Age: ________________ Today’s Date: __________________________ Why did you come into our office today? ______________________________________________________________________________ General Health: Please answer these general health questions. Ignore the last column. Your doctor or nurse will fill that out. Friends and Family For doctor/nurse use Can you talk with your parent(s) or guardian(s) about personal things happening in your life? Yes  No  Sometimes Is there another adult you trust and can talk to if you have a problem? Yes  No Who? Who do you live with? (Please circle all that apply.) Mother Father Guardian Brother or Sister Other: Do you think your family has lots of fun together? Yes  No  Sometimes What do you do for fun? Do you think your parents care about you? Yes  No  Sometimes Do you have a best friend? Yes  No School andWork Do you like school? Yes  No  Sometimes  Not in school What grade are you in? Grade:  Not in school What school do you go to? School:  Not in school Do you do well in school? Yes  No  Sometimes  Not in school How often have you skipped school?  Never  Once or twice  A lot Do you have any learning problems? Yes  No Do you have a job? Yes  No If yes, doing what? Do you know what you want to be when you are older? Yes  No If yes, what? Appearance and Fitness Do you have any concerns or questions about the shape or size of your body or the way you look? Yes  No  Not sure Do you want to gain or lose weight?  Gain  Lose  Neither Have you ever tried to lose weight or control your weight by throwing up, using diet pills or laxatives, or not eating for a day? Yes  No Have you ever had your body pierced (other than ears) or gotten a tattoo? Yes  No  Considering Do you exercise or participate in a sport at least five times per week that makes you sweat or breathe hard for 30 minutes? Yes  No What sport, dance, or exercise programs do you participate in? How many fruits and vegetable portions do you eat each day?  None  1–2  3–4  5–6  7 or more  Depends How many cups of milk, yogurt, ice cream do you eat each day?  None  1–2  3–4  5–6  7 or more  Depends CONFIDENTIAL FORM DO NOT COPY NOT FOR RELEASE Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 Safety/Weapons/Violence For doctor/nurse use Do you wear a seat belt when you ride in a car, truck, or van? Yes  No  Sometimes Do you wear a helmet when you roller blade; skateboard; ride a Yes, for all of the activities circled bike, motorcycle, all-terrain vehicle, mini-bike, scooter; or go  No, for all of the activities circled snowboarding or skiing? (Circle all activities in which you participate.)  Sometimes If sometimes, please explain: Do you or does anyone you live with have a gun, rifle, or other firearm? Yes  No  Not sure Have you ever carried a gun or weapon? Yes  No Have you ever been in trouble with the law? Yes  No Has anyone touched you in a way that made you uncomfortable? Yes  No  Not sure Has anyone ever forced you to have sex? Yes  No  Not sure Has anyone ever hurt you physically or emotionally? Yes  No  Not sure Relationships Are you going out with anyone? Yes  No Who do you find yourself attracted to sexually?  Boys  Girls  Both Do you ever participate in sexual activities, such as touching Yes  No or oral or anal sex? If yes, do you use anything to prevent disease? Yes  No If yes, what do you use? Have you ever had sex with anyone? If yes, answer the Yes  No questions in this section below. If no, do you plan to in the next year?When done answering Yes  No  Not sure this question, go to the section “Tobacco, Alcohol, and Drugs.” How many sexual partners have you had in the past 3 months? Over past 3 months: How many total since you started to have sex? Total: How old were you the first time you had sex (intercourse)? Age: Have you ever had sex with a person of your same sex? Yes  No Do you use anything to prevent pregnancy? Yes  No  Sometimes If yes, what do you use? How often do you and your partner(s) use a condom when you have sex?  Always  Sometimes  Never Have you ever had sex for money or drugs? Yes  No Are you worried about your parents knowing that you are having sex? Yes  No Tobacco, Alcohol, and Drugs Have you or your close friends ever smoked cigarettes or cigars, Yes, I have  No, I have not used snuff, or chewed tobacco? Yes, friends have  No, friends have not  Not sure about friends Have you or your close friends ever gotten drunk on wine, beer, Yes, I have  No, I have not or alcohol? Yes, friends have  No, friends have not  Not sure about friends How much alcohol do you drink at one time?  Do not drink  1–2 drinks  3 or more Do you ever have more than three drinks per occasion?  Do not drink Yes  No In the last year, have you been in a car or other motor vehicle when Yes  No the driver is drunk or has been drinking alcohol or using drugs? (This includes when you were the driver as well as other people.) Would you call your parent(s) or guardian(s) for a ride if you needed Yes  No  Not sure to because the person who was supposed to drive you home had been drinking? (This includes when you were the driver as well as other people.) Have you or your close friends ever used marijuana or other drugs Yes, I have  No, I have not (cocaine, heroin, meth, or ecstasy) or sniffed inhalants (glue, Yes, friends have  No, friends have not gasoline, or solvents)?  Not sure Have you ever used a prescription drug to get high? Yes  No  Not sure ACOG ADOLESCENT VISIT QUESTIONNAIRE (continued) Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 ACOG ADOLESCENT VISIT QUESTIONNAIRE (continued) Have you ever used alcohol or drugs so much that you could not  Do not use drugs or alcohol remember what happened (had a blackout)? Yes  No Have you ever missed work or school because of using alcohol  Do not use drugs or alcohol or drugs? Yes  No Emotions Do you have more happy days or unhappy days?  Happy  Unhappy Have you ever seriously thought about hurting yourself? Yes  No Do you get nervous or anxious more than other people do? Yes  No During the past year, have you had any major good or bad changes  Good  Bad  No changes in your life (death of someone close, loss of a pet, birth, graduation,  Some good, some bad moving, change of school, ending or starting a close friendship or romantic relationship)? Tell me something good about yourself. What would you like to discuss with our nurses and doctors today?__________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Source: American Medical Association, Copyright 1998. Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 ACOG ADOLESCENT VISIT RECORD I. General Information Date: _________________Name: ___________________________________________________________ LAST FIRST MIDDLE Date of Birth:_______________________________Record Number:______________________________ Primary Physician: __________________________Referral Source: ______________________________ Contact information Patient phone: ____________________________________________ May say, “Call physician”? Yes  No May leave test results? Yes  No Parent name: _____________________________________________________________________________________________________________________ Parent phone: ____________________________________________________Parent e-mail:____________________________________________________ Patient Addressograph Current age: Complaint(s), if any: Current medications: Allergies: II. History FOR PROBLEMVISIT ONLY—History of Present Illness (HPI) FOR PROBLEMVISIT ONLY—HPI elements: (Location, severity, timing, (please describe, if any): modifying factors, quality, duration, context, associated signs and symptoms) Menstrual History Response Details/Notes Response Details/Notes Age at menarche Last Menstrual Period Length of periods Normal or abnormal Cycle length Cramping Premenstrual symptoms Past Medical and Family History Past Medical History (+) Pos (0) Neg Details/Remarks Past and chronic illnesses (asthma, diabetes mellitus, hypertension, seizure disorder, migraines, arthritis, rheumatic fever, hepatitis, cancer, sickle cell anemia, pneumonia, tuberculosis or exposure to tuberculosis, blood clot, hyperlipidemia, scoliosis, other) Surgical procedures Physical trauma, injuries, or fractures Hospitalizations Transfusions of blood products Previous cervical cytology Date: Normal/Abnormal/____ Past Family History High blood pressure Parent with cholesterol level above 240 mg/dL Obesity Diabetes Parent or grandparent death from heart attack or stroke at an age younger than 55 years, coronary artery disease, peripheral vascular disease, cerebrovascular disease Insurance Carrier or Medicaid No: _________________________________________________________ Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 A nurse or nursing assistant, depending on staff capabilities and facilities, can obtain information for all shaded areas of the record. Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 Past Medical and Family History (continued) Allergies or asthma Cancer Seizures Eating disorder Depression, bipolar disorder, or anxiety disorder Blood clots Tobacco, alcohol, or drug addiction If sexually active, contraception and sexually transmitted disease Details/Notes prevention method(s): Use of condoms: Frequency of method use: Number of current partners: Age of initial coitus: Participate in oral or anal sex: Number of past partners: History of sexual abuse or violence: Pregnancies: G _____ P _____ AB _____ Sexually transmitted diseases, including pelvic inflammatory disease, herpes simplex virus, and human papillomavirus: Vaginitis: III. Review of Systems (+) Pos (0) Neg Details/Remarks Constitutional (weight loss or gain, fever, malaise, appetite and eating habits) Eyes Ears, nose, mouth or throat problems Cardiovascular Respiratory Gastrointestinal (nausea, vomiting, bowel movements) Genitourinary (urination problems, vaginal discharge) Musculoskeletal (muscle or joint pain, scoliosis) Integumentary (acne) Breast tenderness, mass Neurologic (headaches) Psychiatric (depression, anxiety, exposure to violence or abuse) Endocrine (hirsutism, acne, heat or cold intolerance) Hematologic or lymphatic (blood disorder, anemia) Allergic or immunologic ACOG ADOLESCENT VISIT RECORD (continued) A nurse or nursing assistant, depending on staff capabilities and facilities, can obtain information for all shaded areas of the record. Past Reproductive Health History IV. Health Guidance and Counseling Positive From Adolescent Visit Questionnaire: Details/Notes Positive From Parent Questionnaire Details/Notes Routine as appropriate: Routine as appropriate: Tobacco Emergency contraception Alcohol and other drugs Sexually transmitted diseases, including human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) Drinking and driving* Sexual victimization risk reduction† Diet (calcium, weight management, Pregnancy counseling (options, prenatal care, folic acid) school) Exercise Violence Responsible sexual behavior (abstinence Conflict resolution or contraception) Condoms (how to acquire, use, and talk Seat belts or helmets with partner) Suicidal ideation Others Others *Encourage adolescents and their parents to develop agreements for picking up adolescents who have consumed alcohol or other substances. †Discuss roles of alcohol and other drugs in increasing risks and in having negative, unintended consequences. ACOG ADOLESCENT VISIT RECORD (continued) VI. Physical Examination. Check “not performed” if not examined (required if history indicates and at least once at ages 12–14 years, 15–17 years, and 18–21 years) Body Area or Body Area or Organ System Normal Abnormal Not Performed Organ System Normal Abnormal Not Performed Skin Breasts Tanner stage: Eyes Genitourinary Ears, nose, mouth, or throat Vulva or external (teeth and gums) genitalia Neck (thyroid, masses) Pubic hair Tanner stage: Cardiovascular (peripheral Urethral meatus system or auscultation) Respiratory (effort, Urethra auscultation) Weight Height Blood Pressure BMI* Temperature Pulse BMI for Age *Body mass index (BMI) is computed as weight (in kilograms) divided by height in meters squared. Using pounds and inches, multiply the division results by 703. To determine prepregnancy weight-for-height status, go to the BMI chart. (See related charts at end.) V.Vital Signs Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 A nurse or nursing assistant, depending on staff capabilities and facilities, can complete all shaded areas of the record. VI. Physical Examination, continued Body Area or Organ System Normal Abnormal Not Performed Body Area or Organ System Normal Abnormal Not Performed Abdomen (masses, Kidney or bladder tenderness, hernia, hepatosplenomegaly) Musculoskeletal Vagina Extremities Cervix Hematologic, lymphatic, or Uterus immunologic (lymph nodes) Neurologic Adnexa Psychiatric Anus or perineum Gastrointestinal (digital rectal examination) Details on Physical Examination _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ VII.Testing Ordered and Performed Tests Date Results General Cholesterol* Lipoprotein profile† Tuberculin‡ Gynecologic Cervical cytology§ Gonorrhea|| Chlamydia|| Syphilis¶ HIV|| Other *Adolescents with parental cholesterol level greater than 240 mg/dL should be screened for total blood cholesterol level (nonfasting) at least once. Adolescents with either unknown family history or multiple risk factors may be screened for total serum cholesterol level (nonfasting) at least once. †Adolescents with a parent or grandparent with coronary artery disease, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death at an age younger than 55 years should be screened with a fasting lipoprotein profile. ‡Adolescents should receive purified protein derivative testing if they have been exposed to active tuberculosis; have lived in a homeless shelter, been incarcerated, or lived in another long-term care facility; have lived in an endemic area; are currently working in a health care setting; are HIV positive; are medically underserved or low income; have a history of substance abuse, including alcoholism; or have medical risk factors known to increase risk of disease if infected with Mycobacterium tuberculosis. §Cervical cytology should be obtained at age 21 years. || Routine screening for HIV, chlamydial, and gonorrheal infection should be performed for all sexually active adolescents. ¶Serologic testing for syphilis should be conducted on sexually active adolescents who have a history of prior sexually transmitted diseases, multiple sexual partners, exchanged sex for drugs or money, used illicit drugs, been admitted to jail or other detention facility, or lived in an endemic area. Assessment Plan VIII. Assessment and Plan ACOG ADOLESCENT VISIT RECORD (continued) FOR PROBLEMVISIT ONLY—If E/M Code selected based on time: Time spent counseling: Total time with patient: Topics of counseling: A nurse or nursing assistant, depending on staff capabilities and facilities, can complete all shaded areas of the record. Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 ACOG ADOLESCENT VISIT RECORD (continued) Date: _________________Name: ___________________________________________________________ LAST FIRST MIDDLE Record Number:_________________________________________________________________________ Contact information Patient phone: ____________________________________________ May say, “Call physician”? Yes  No May leave test results? Yes  No Patient Addressograph Progress Sheet Response Details/Notes Response Details/Notes Height Last menstrual period Weight Recent onset of sexual activity BMI Change in sexual partner Blood pressure Tobacco, alcohol, or drug use New findings from Adolescent Visit Questionnaire Physical Examination. Check “not performed” if not examined (required if history indicates and at least once at ages 12–14 years, 15–17 years, and 18–21 years) Body Area or Body Area or Organ System Normal Abnormal Not Performed Organ System Normal Abnormal Not Performed Skin Breasts Tanner stage: Eyes Genitourinary Ears, nose, mouth, or throat Vulva or external (teeth and gums) genitalia Neck (thyroid, masses) Pubic hair Tanner stage: Cardiovascular (peripheral Urethral meatus system or auscultation) Respiratory (effort, Urethra auscultation) Abdomen (masses, Kidney or bladder tenderness, hernia, hepatosplenomegaly) Musculoskeletal Vagina Extremities Cervix Hematologic, lymphatic, or Uterus immunologic (lymph nodes) Neurologic Adnexa Psychiatric Anus or perineum Gastrointestinal (digital rectal examination) Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 Details on Physical Examination _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ ACOG ADOLESCENT VISIT RECORD (continued) Assessment Plan Assessment and Plan Progress Notes Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 ACOG ADOLESCENT VISIT RECORD (continued) Body Mass Index Chart Height m 1.24 1.27 1.3 1.32 1.35 1.37 1.4 1.42 1.45 1.47 1.5 1.52 1.55 1.57 1.6 1.63 1.65 1.68 1.7 1.73 1.75 1.78 1.8 1.83 1.85 1.88 1.9 1.93 in 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 Weight kg lb 20 45 13.2 12.7 12.2 11.7 11.3 10.8 10.5 10.1 9.7 9.4 9.1 8.8 8.5 23 50 14.6 14.1 13.5 13.0 12.5 12.1 11.6 11.2 10.8 10.4 10.1 9.8 9.4 9.1 8.9 8.6 8.3 25 55 16.1 15.5 14.9 14.3 13.8 13.3 12.8 12.3 11.9 11.5 11.1 10.7 10.4 10.1 9.7 9.4 9.2 8.9 27 60 17.6 16.9 16.2 15.6 15.0 14.5 13.9 13.5 13.0 12.5 12.1 11.7 11.3 11.0 10.6 10.3 10.0 9.7 9.4 9.1 29 65 19.0 18.3 17.6 16.9 16.3 15.7 15.1 14.6 14.1 13.6 13.1 12.7 12.3 11.9 11.5 11.2 10.8 10.5 10.2 9.9 9.6 32 70 20.5 19.7 18.9 18.2 17.5 16.9 16.3 15.7 15.1 14.6 14.1 13.7 13.2 12.8 12.4 12.0 11.6 11.3 11.0 10.6 10.3 10.0 34 75 22.0 21.1 20.3 19.5 18.8 18.1 17.4 16.8 16.2 15.7 15.1 14.6 14.2 13.7 13.3 12.9 12.5 12.1 11.7 11.4 11.1 10.8 10.5 36 80 23.4 22.5 21.6 20.8 20.0 19.3 18.6 17.9 17.3 16.7 16.2 15.6 15.1 14.6 14.2 13.7 13.3 12.9 12.5 12.2 11.8 11.5 11.2 10.8 39 85 24.9 23.9 23.0 22.1 21.3 20.5 19.8 19.1 18.4 17.8 17.2 16.6 16.1 15.5 15.1 14.6 14.1 13.7 13.3 12.9 12.6 12.2 11.9 11.5 11.2 41 90 26.4 25.3 24.3 23.4 22.5 21.7 20.9 20.2 19.5 18.8 18.2 17.6 17.0 16.5 15.9 15.4 15.0 14.5 14.1 13.7 13.3 12.9 12.6 12.2 11.9 11.6 43 95 27.8 26.7 25.7 24.7 23.8 22.9 22.1 21.3 20.6 19.9 19.2 18.6 17.9 17.4 16.8 16.3 15.8 15.3 14.9 14.4 14.0 13.6 13.2 12.9 12.5 12.2 45 100 29.3 28.1 27.0 26.0 25.0 24.1 23.2 22.4 21.6 20.9 20.2 19.5 18.9 18.3 17.7 17.2 16.6 16.1 15.7 15.2 14.8 14.3 13.9 13.6 13.2 12.8 12.5 12.2 48 105 30.7 29.5 28.4 27.3 26.3 25.3 24.4 23.5 22.7 21.9 21.2 20.5 19.8 19.2 18.6 18.0 17.5 16.9 16.4 16.0 15.5 15.1 14.6 14.2 13.9 13.5 13.1 12.8 50 110 32.2 30.9 29.7 28.6 27.5 26.5 25.6 24.7 23.8 23.0 22.2 21.5 20.8 20.1 19.5 18.9 18.3 17.8 17.2 16.7 16.2 15.8 15.3 14.9 14.5 14.1 13.7 13.4 52 115 33.7 32.3 31.1 29.9 28.8 27.7 26.7 25.8 24.9 24.0 23.2 22.5 21.7 21.0 20.4 19.7 19.1 18.6 18.0 17.5 17.0 16.5 16.0 15.6 15.2 14.8 14.4 14.0 54 120 35.1 33.7 32.4 31.2 30.0 28.9 27.9 26.9 26.0 25.1 24.2 23.4 22.7 21.9 21.3 20.6 20.0 19.4 18.8 18.2 17.7 17.2 16.7 16.3 15.8 15.4 15.0 14.6 57 125 36.6 35.2 33.8 32.5 31.3 30.1 29.0 28.0 27.0 26.1 25.2 24.4 23.6 22.9 22.1 21.5 20.8 20.2 19.6 19.0 18.5 17.9 17.4 17.0 16.5 16.0 15.6 15.2 59 130 38.1 36.6 35.1 33.8 32.5 31.3 30.2 29.1 28.1 27.2 26.3 25.4 24.6 23.8 23.0 22.3 21.6 21.0 20.4 19.8 19.2 18.7 18.1 17.6 17.1 16.7 16.2 15.8 61 135 39.5 38.0 36.5 35.1 33.8 32.5 31.4 30.3 29.2 28.2 27.3 26.4 25.5 24.7 23.9 23.2 22.5 21.8 21.1 20.5 19.9 19.4 18.8 18.3 17.8 17.3 16.9 16.4 64 140 41.0 39.4 37.8 36.4 35.0 33.8 32.5 31.4 30.3 29.3 28.3 27.3 26.4 25.6 24.8 24.0 23.3 22.6 21.9 21.3 20.7 20.1 19.5 19.0 18.5 18.0 17.5 17.0 66 145 42.5 40.8 39.2 37.7 36.3 35.0 33.7 32.5 31.4 30.3 29.3 28.3 27.4 26.5 25.7 24.9 24.1 23.4 22.7 22.0 21.4 20.8 20.2 19.7 19.1 18.6 18.1 17.6 68 150 43.9 42.2 40.5 39.0 37.5 36.2 34.9 33.6 32.5 31.3 30.3 29.3 28.3 27.4 26.6 25.7 25.0 24.2 23.5 22.8 22.1 21.5 20.9 20.3 19.8 19.3 18.7 18.3 70 155 45.4 43.6 41.9 40.3 38.8 37.4 36.0 34.7 33.5 32.4 31.3 30.3 29.3 28.3 27.5 26.6 25.8 25.0 24.3 23.6 22.9 22.2 21.6 21.0 20.4 19.9 19.4 18.9 73 160 46.8 45.0 43.2 41.6 40.0 38.6 37.2 35.9 34.6 33.4 32.3 31.2 30.2 29.3 28.3 27.5 26.6 25.8 25.1 24.3 23.6 23.0 22.3 21.7 21.1 20.5 20.0 19.5 75 165 48.3 46.4 44.6 42.9 41.3 39.8 38.3 37.0 35.7 34.5 33.3 32.2 31.2 30.2 29.2 28.3 27.5 26.6 25.8 25.1 24.4 23.7 23.0 22.4 21.8 21.2 20.6 20.1 77 170 49.8 47.8 45.9 44.2 42.5 41.0 39.5 38.1 36.8 35.5 34.3 33.2 32.1 31.1 30.1 29.2 28.3 27.4 26.6 25.8 25.1 24.4 23.7 23.1 22.4 21.8 21.2 20.7 79 175 49.2 47.3 45.5 43.8 42.2 40.7 39.2 37.9 36.6 35.3 34.2 33.1 32.0 31.0 30.0 29.1 28.2 27.4 26.6 25.8 25.1 24.4 23.7 23.1 22.5 21.9 21.3 82 180 50.6 48.7 46.8 45.0 43.4 41.8 40.4 38.9 37.6 36.4 35.2 34.0 32.9 31.9 30.9 30.0 29.0 28.2 27.4 26.6 25.8 25.1 24.4 23.7 23.1 22.5 21.9 84 185 50.0 48.1 46.3 44.6 43.0 41.5 40.0 38.7 37.4 36.1 35.0 33.8 32.8 31.8 30.8 29.9 29.0 28.1 27.3 26.5 25.8 25.1 24.4 23.8 23.1 22.5 86 190 49.4 47.6 45.8 44.2 42.6 41.1 39.7 38.4 37.1 35.9 34.7 33.7 32.6 31.6 30.7 29.8 28.9 28.1 27.3 26.5 25.8 25.1 24.4 23.7 23.1 88 195 50.7 48.8 47.0 45.3 43.7 42.2 40.8 39.4 38.1 36.8 35.7 34.5 33.5 32.4 31.5 30.5 29.6 28.8 28.0 27.2 26.4 25.7 25.0 24.4 23.7 91 200 50.1 48.2 46.5 44.8 43.3 41.8 40.4 39.1 37.8 36.6 35.4 34.3 33.3 32.3 31.3 30.4 29.5 28.7 27.9 27.1 26.4 25.7 25.0 24.3 93 205 49.4 47.6 46.0 44.4 42.8 41.4 40.0 38.7 37.5 36.3 35.2 34.1 33.1 32.1 31.2 30.3 29.4 28.6 27.8 27.0 26.3 25.6 25.0 95 210 48.8 47.1 45.4 43.9 42.4 41.0 39.7 38.4 37.2 36.0 34.9 33.9 32.9 31.9 31.0 30.1 29.3 28.5 27.7 27.0 26.2 25.6 98 215 50.0 48.2 46.5 44.9 43.4 42.0 40.6 39.3 38.1 36.9 35.8 34.7 33.7 32.7 31.7 30.8 30.0 29.2 28.4 27.6 26.9 26.2 100 220 49.3 47.6 46.0 44.4 43.0 41.6 40.2 39.0 37.8 36.6 35.5 34.5 33.4 32.5 31.6 30.7 29.8 29.0 28.2 27.5 26.8 102 225 50.4 48.7 47.0 45.4 43.9 42.5 41.1 39.9 38.6 37.4 36.3 35.2 34.2 33.2 32.3 31.4 30.5 29.7 28.9 28.1 27.4 104 230 49.8 48.1 46.4 44.9 43.5 42.1 40.7 39.5 38.3 37.1 36.0 35.0 34.0 33.0 32.1 31.2 30.3 29.5 28.7 28.0 107 235 49.1 47.5 45.9 44.4 43.0 41.6 40.3 39.1 37.9 36.8 35.7 34.7 33.7 32.8 31.9 31.0 30.2 29.4 28.6 109 240 50.2 48.5 46.9 45.3 43.9 42.5 41.2 39.9 38.7 37.6 36.5 35.4 34.4 33.5 32.5 31.7 30.8 30.0 29.2 111 245 49.5 47.8 46.3 44.8 43.4 42.0 40.8 39.5 38.4 37.2 36.2 35.2 34.2 33.2 32.3 31.5 30.6 29.8 113 250 50.5 48.8 47.2 45.7 44.3 42.9 41.6 40.3 39.2 38.0 36.9 35.9 34.9 33.9 33.0 32.1 31.2 30.4 116 255 49.8 48.2 46.6 45.2 43.8 42.4 41.2 39.9 38.8 37.7 36.6 35.6 34.6 33.6 32.7 31.9 31.0 118 260 49.1 47.5 46.1 44.6 43.3 42.0 40.7 39.5 38.4 37.3 36.3 35.3 34.3 33.4 32.5 31.6 120 265 50.1 48.5 46.9 45.5 44.1 42.8 41.5 40.3 39.1 38.0 37.0 35.9 35.0 34.0 33.1 32.3 122 270 49.4 47.8 46.3 44.9 43.6 42.3 41.0 39.9 38.7 37.7 36.6 35.6 34.7 33.7 32.9 125 275 48.7 47.2 45.8 44.4 43.1 41.8 40.6 39.5 38.4 37.3 36.3 35.3 34.4 33.5 127 280 49.6 48.1 46.6 45.2 43.8 42.6 41.3 40.2 39.0 38.0 36.9 35.9 35.0 34.1 129 285 50.5 48.9 47.4 46.0 44.6 43.3 42.1 40.9 39.7 38.6 37.6 36.6 35.6 34.7 132 290 49.8 48.3 46.8 45.4 44.1 42.8 41.6 40.4 39.3 38.3 37.2 36.2 35.3 134 295 50.6 49.1 47.6 46.2 44.8 43.6 42.3 41.1 40.0 38.9 37.9 36.9 35.9 136 300 49.9 48.4 47.0 45.6 44.3 43.0 41.8 40.7 39.6 38.5 37.5 36.5 Centers for Disease Control and Prevention. BMI—Body Mass Index: about BMI for children and teens. Available at: http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/ about_childrens_BMI.htm. Retrieved August 8, 2006. ACOG ADOLESCENT VISIT RECORD (continued) Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 12 14 16 18 20 22 24 26 28 30 32 34 BMI 12 14 16 18 20 22 24 26 28 30 32 34 BMI 85th 90th 95th 75th 50th 25th 10th 5th Underweight (5th percentile and below) Overweight (95th percentile and above) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Age (years) 17 18 19 20 At risk of Overweight (85th–94th percentile) Body Mass Index by Age: Girls Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2002). 78 76 74 72 70 68 66 64 62 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30 78 76 74 72 70 68 66 64 62 60 58 56 54 52 50 48 46 44 42 40 38 36 34 32 30 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 95th 90th 25th 10th cm in cm in in in Age (years) 5th 50th 75th 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 Height-for-Age Percentiles: Girls Aged 2–20 Years in the United States ACOG ADOLESCENT VISIT RECORD (continued) Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2002). Copyright © 2010, The American College of Obstetricians and Gynecologists (AA414) 12345/43210 ACOG ADOLESCENT VISIT RECORD (continued) Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). Weight-for-Age Percentiles: Girls Aged 2–20 Years in the United States NOTES T H E A M E R I C A N C O L L E G E O F O B S T E T R I C I A N S A N D G Y N E C O L O G I S T S