Name:_________________________
Date of Birth/Age:_______________
Male:___
Female:___
MR# or SS#:___________________
Ethnicity:______________________
Medications:___________________
Old Records:___________________
Allergies:______________________
Smoker:_____
ETS:________________
Date:_______________
Screening: 1. Height/weight
Annual Assessment of Risk Factors:
____Above or below healthy weight range for height
Counseling Provided:
Screening: 2. Blood pressure
Annual Assessment of Risk Factors:
____Screen during office visits
Counseling Provided:
Screening: 3. Vision
Annual Assessment of Risk Factors:
____Screen at approximately 3-4 yr
____Eyes turning inward or outward
____Squinting
____Headaches
____Not doing as well in school as before
____Blurred or double vision
Counseling Provided:
Screening: 4-6. PKU, hemoglobinopathies, hypothyroidism
Annual Assessment of Risk Factors:
____Screening tests done in first 7 days after delivery
____Records from hospital should be in chart
Counseling Provided:
Screening: 7. Hearing
Annual Assessment of Risk Factors:
____Family history of hereditary childhood sensorineural hearing loss
____Congenital perinatal infection with herpes
____Perinatal infection with herpes, syphilis, rubella,
cytomegalovirus, or toxoplasmosis
____Malformations involving head or neck
____Birth weight below 1500 g
____Bacterial meningitis
____Hyperbilirubinemia requiring exchange transfusion
____Severe perinatal asphyxia
____Ototoxic medications
Counseling Provided:
Screening: 8. Anemia (for those at high risk)
Annual Assessment of Risk Factors:
____Lives in poverty
____Black, Native American, or Alaska Native
____Immigrant from developing country
____Preterm and low birth weight infant
____Drinks primarily unfortified cow's milk
Counseling Provided:
Screening: 9. Cholesterol (for those at high risk)
Annual Assessment of Risk Factors:
____Has a parent who has high cholesterol
____Has a parent or grandparent who died suddenly or had
heart disease before age 55
____Child is obese
____Has high blood pressure
Counseling Provided:
Screening: 10. Lead (for those at high risk)
Annual Assessment of Risk Factors:
____Lived in or regularly visited a house built before 1950
____Lived in or regularly visited a house built before 1978 with recent,
ongoing, or planned renovation or remodeling
____Had a brother or sister, housemate, or playmate followed or treated
for lead poisoning
____Is anemic
Counseling Provided:
Screening: 11. Tuberculin skin test (for those at high risk)
Annual Assessment of Risk Factors:
____Close contact with a person who has active tuberculosis
____Occupational high risk (health care, correctional, residential, etc.)
____Lived in endemic area in the past year (SE Asia, Africa, Latin America)
____Medical risk factors (e.g., diabetes, HIV, alcoholism)
Counseling Provided:
Screening: 12. HIV test (for those at high risk)
Annual Assessment of Risk Factors:
____High-risk mother and antibody status of mother is unknown
____Inconsistent and incorrect use of barrier contraceptives
____Has or has had any one of the following risk factors:
previous STD, multiple sex partners, or shared needles
Counseling Provided:
Screening: 13. Chlamydia
Annual Assessment of Risk Factors:
____Is sexually active and > 25 yr
Counseling Provided:
Screening: 14. Pap smear
Annual Assessment of Risk Factors:
____Is sexually active and has been over 3 yr since last test
Counseling Provided:
Counseling: 15. Sleep position
Annual Assessment of Risk Factors:
____Places baby on stomach
Counseling Provided:
Counseling: 16. Injury prevention
Annual Assessment of Risk Factors:
____Does not use child safety car seats/booster seats
____Does not use lap/shoulder belts
____Does not use a bicycle helmet
____Does not have hot-water heater temperature < 120-130°F
____Medicines, chemicals/poisons, or firearms are accessible to children
____Does not have window/stair guards or a pool fence
____Does not have syrup of ipecac or the poison control phone number
____Does not have working smoke detectors in the home
Counseling Provided:
Counseling: 17. Nutrition
Annual Assessment of Risk Factors:
____Mother does not breast-feed
____Does not limit intake of fat and cholesterol, maintain calorie
balance in diet, or eat foods containing fiber
____Inadequate calcium intake for teen girls
Counseling Provided:
Counseling: 18. Physical activity
Annual Assessment of Risk Factors:
____Does not get 30 minutes of physical activity most days
Counseling Provided:
Counseling: 19. Oral health
Annual Assessment of Risk Factors:
____Poor dental hygiene (e.g., does not brush with a fluoride
toothpaste and floss daily)
____Does not see a dentist regularly
____Smokes or chews tobacco and/or drinks alcohol
Counseling Provided:
Counseling: 20. Sun exposure
Annual Assessment of Risk Factors:
____Immunosuppression
____Family history of skin cancer
____Freckles and poor tanning ability
____Light skin, hair, and eye color
Counseling Provided:
Counseling: 21. Tobacco use
Annual Assessment of Risk Factors:
____Currently smokes cigarettes, cigars, or pipes or uses smokeless tobacco
____Lives with an adult who smokes inside the home
Counseling Provided:
Counseling: 22. Alcohol/drug use
Annual Assessment of Risk Factors:
____Drinks more than 2 drinks/day (men) or 1 drink/ day (women)
(quantity______________ frequency____________)
____Uses or has used "street drugs"
____Has had medical and/ or social problems related to alcohol or drug use
Counseling Provided:
Counseling: 23. Unintended pregnancy/STDs/HIV
Annual Assessment of Risk Factors:
____Sexually active male or sexually active female of childbearing age
____Does not desire a pregnancy/is not using a reliable birth control method
Has or has had previous STD, multiple sex partners, or shared needles
Counseling Provided:
Counseling: 24. Multivitamin with folic acid
Annual Assessment of Risk Factors:
____Sexually active female of childbearing age
Counseling Provided:
Notes/Instructions:
Completed by:
Date:
Reviewed by clinician:
Date:
Note: Information is based on U.S. Preventive Services Task Force recommendations.
ETS = environmental tobacco smoke; Td = tetanus-diphtheria; BMI = body mass index; STD = sexually transmitted disease; HIV = human immunodeficiency virus; PPD = tuberculin purified protein derivative; INH = isoniazid.