Well Adolescent (AWJ)

John Smith is here for a 15-year-old well child check. Past/Current Medical Problems: Asthma - well controlled with albuterol inhaler as needed. No recent specialist consults. Acute problems or concerns today: Mild acne on face, no other concerns. Review of Diet/Nutrition: Diet includes a variety of fruits, vegetables, and proteins. Drinks water regularly. Review of Physical Activity: Engages in soccer practice three times a week and enjoys cycling on weekends. Education & Employment: Currently in 10th grade, achieving good grades. No behavioral, learning, or attention issues. Not in special education. Aspires to attend university. Screen time: Approximately 3 hours/day spent on screen time. Home & Environment: Lives at home with mother, father, and younger sister. Smoke exposure: No Guns in household: No guns in the house. Review of Sleep: Sleeps 8 hours per night, regular bedtime at 10 PM, sleeps through the night, no snoring. Dental Hx: Visited dentist 6 months ago, brushes teeth twice daily. Review of Elimination: No issues, no constipation. Physical Exam: Mild acne on face, otherwise normal exam. Confidential Adolescent (14-17 yo) Findings Home: Feels safe at home. Education: 10th grade, no issues at school, no bullying or fighting, good academic performance. Activities: Enjoys playing soccer and video games, no job or volunteering currently. Drugs: No smoking, vaping, drugs, or alcohol use. Sexuality and Gender: Male, uses he/him pronouns, attracted to females, has not had sex before. Mental Health: No depression, anxiety, thoughts of suicide, or self-harm. Assessment and Plan: John Smith is here for a Well Adolescent Visit. - Immunizations are up to date. - Depression and anxiety screening performed. - Hearing screening and visual acuity performed. - Tuberculosis risk assessment completed. - Anemia risk assessment completed. - Social determinants of health assessed and discussed via PRAPARE. - Discussed oral health, healthy eating, physical activity and sleep, school performance, emotional well-being, relationships with family and peers, coping with stress and decision making, risk reduction (STIs, pregnancy, drugs, alcohol, and tobacco) and safety (helmet use, sun protection). Will return in a year for next well child check, sooner if needed/as below. Acne: Mild acne on face. Plan to start over-the-counter benzoyl peroxide wash and follow up in 3 months if no improvement.