Plymouth Family Physicians

Health Maintenance Exam Age 13-18

The following will assist us in providing thorough care and in obtaining needed services for your infant or child.

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

PARENTS NEED TO BRING IMMUNIZATION RECORDS WITH THEM TO THIS VISIT!

Name (required)

E-mail

Birth Date

Age

Any new family health problems?

Who lives in your home?

RECENT SYMPTOMS (check any that apply today):

GENERAL:

Fevers or chills
Weight change
Appetite change

EYES:

Vision concerns
Eye discharge or discomfort

Please provide the following:

Eye Care provider:

Date of last exam?

EARS:

Change in hearing
Ear pain
Nasal congestion or bleeding

MOUTH:

Mouth sores
Sore throat
Dental problems

Please provide the following:

Dental provider:

Date of last exam?

Heart:

Chest pain
Heart concerns

Lungs:

Cough
Shortness of breath

BREASTS:

Pain
Nipple discharge
Masses

Bowels:

Abdominal pain
Change in bowels
Bleeding
Heartburn

Urinary:

Urinary problems
Menstrual problems

Muscle/Bone:

Injury to muscle or joint
Joint, muscle or back pain

Brain, Spine:

Headaches
Coordination problems

SKIN:

Rashes
Concerning lesions

Metabolism:

Unusual thirst
Weight loss

Emotions:

Depression
Anxiety
School problems
Fears

ALLERGY:

Allergy symptoms

Medications (prescription or non-prescription)

Medication allergies

Sleeping - typical wake and sleep times

Any problems at home or at school?

Favorite activities?

How many hours of TV per day?

TV in your room? Yes No

How often do you use your seat belt?

How many meals do you eat per day?

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.