GREIG HEALTH RECORD VISIT NOTE, AGES 6 TO 17

Patient: [Name, age, pronouns]
Date of birth: [Date]
Visit date: [Date]
Age group: [6 to 9, 10 to 13, or 14 to 17]
Came with: [Parent or caregiver, or on their own]
Clinician: [Name, credentials]

BACKGROUND
Family history and risk factors: [Early heart disease, high cholesterol, diabetes, mental illness, or substance use in the family]
Allergies and medicines: [Allergies with reactions; regular medicines, vitamins, and natural health products]
Since the last checkup: [Illnesses, injuries, emergency visits, new diagnoses]
Concerns today: [From the child or teen, then from the parent]

MEASUREMENTS
Height and weight: [cm and kg, with percentiles on the WHO Growth Charts for Canada]
BMI: [Value, BMI-for-age percentile, and the trend since the last visit]
Blood pressure: [Reading, and how it compares with the norm for age, sex, and height]
Vision: [Acuity in each eye; date of the last eye exam]
Hearing: [Concerns, earbud volume, loud noise at work or play]

SCHOOL AND DEVELOPMENT
School: [Grade, report card, reading and math, learning or attention concerns]
Friends and activities: [Friendships, bullying, sports, clubs, part-time job]
Family: [Who lives at home, how they get along, discipline, recent changes]
Puberty: [Body changes, periods and any problems with them, questions]

NUTRITION, ACTIVITY, SLEEP, AND SCREENS
Eating: [Breakfast, vegetables and fruit, sweet drinks, fast food, supplements]
Body image: [Worries about weight or shape, dieting, skipped meals]
Activity: [Minutes a day of moderate to vigorous activity; sports and walking or biking to school]
Sleep: [Bedtime, wake time, hours a night, devices in the bedroom, snoring]
Screens: [Hours a day outside school; social media and gaming]

PSYCHOSOCIAL INTERVIEW, FROM ABOUT AGE 12
Confidentiality: [What stays private and when it can't, explained to youth and parent; minutes alone with the youth]
Home, school, and friends: [The youth's own account]
Mood: [Low mood, worry, stress; tool and score, such as PHQ-A or GAD-7]
Self-harm and suicide: [Thoughts, plans, past attempts, access to means; or none]
Substances: [Vaping, tobacco, alcohol, cannabis, other drugs; tool and score, such as CRAFFT]
Abuse and violence: [Harm at home, at school, online, or in a relationship; or none]
Sexual health: [Dating, orientation and gender identity if shared, consent, contraception and condoms, STI testing if sexually active]

SAFETY
In the car and on the road: [Booster seat until 145 cm and a good belt fit, seat belt, helmet, driving and riding with impaired drivers]
Water, sun, and home: [Swimming ability, life jackets, sunscreen, smoke and carbon monoxide alarms, second-hand smoke]
Firearms and online life: [Firearms at home and how they are locked; contact with strangers, image sharing]
Other: [Trampolines, workplace safety, other topics for this age]

EXAMINATION
General: [Appearance, mood, how the child relates to you]
Findings: [Head and neck, teeth, heart, lungs, abdomen, back and spine, skin and acne, genitourinary when indicated]
Sexual maturity rating: [Tanner stage]

PREVENTION
Dental: [Last dental visit, brushing with fluoride toothpaste, sealants, mouthguard for sports]
Immunizations: [Status against the provincial schedule, doses given today, school program doses still due]
Influenza: [Given, booked, or declined]
Tests only if indicated: [Lipids for a family history, STI testing, TB skin test for risk factors, hemoglobin or ferritin]

ASSESSMENT AND PLAN
Assessment: [Healthy child or teen, or the concerns found]
Plan: [Each concern with its next step, referrals, and resources given]
Advice given: [The age-specific guidance covered today, and what the family agreed to try]
Shared with the parent: [What the youth agreed could be shared; or not applicable]
Next preventive visit: [In 1 to 2 years, or sooner for follow-up]

Signed: [Clinician name, credentials, date and time]