Healthy Teen (AWJ) Template

s10.ai is here for a 15-year-old well child examination.
Past/Current Medical Problems:  
Asthma - effectively managed with albuterol inhaler as required. No recent consultations with specialists.
Acute problems or concerns today:  
Mild facial acne, no additional concerns.
Review of Diet/Nutrition:  
Diet consists of a range of fruits, vegetables, and proteins. Regular water intake.
Review of Physical Activity:  
Participates in soccer practice thrice weekly and enjoys cycling on weekends.
Education & Employment:  
Currently in 10th grade, maintaining good academic performance. No behavioral, learning, or attention difficulties. Not enrolled in special education. Aspires to attend university.
Screen time: Approximately 3 hours/day spent on screen time.
Home & Environment: Resides at home with mother, father, and younger sister.  
Smoke exposure: None  
Guns in household: No firearms present.
Review of Sleep: Sleeps 8 hours per night, consistent 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 facial acne, otherwise normal examination.
Confidential Adolescent (14-17 yo) Findings  
Home: Feels secure at home.  
Education: 10th grade, no school issues, no bullying or fighting, good academic performance.  
Activities: Enjoys playing soccer and video games, not currently employed or volunteering.  
Drugs: No use of smoking, vaping, drugs, or alcohol.  
Sexuality and Gender: Male, uses he/him pronouns, attracted to females, has not engaged in sexual activity.  
Mental Health: No signs of depression, anxiety, suicidal thoughts, or self-harm.
Assessment and Plan:  
s10.ai is here for a Well Adolescent Visit.  
- Immunizations are current.  
- Depression and anxiety screening conducted.  
- Hearing and visual acuity screenings performed.  
- Tuberculosis risk assessment completed.  
- Anemia risk assessment completed.  
- Social determinants of health evaluated and discussed via PRAPARE.  
- Discussed oral health, nutrition, physical activity and sleep, academic performance, emotional well-being, relationships with family and peers, stress management and decision making, risk reduction (STIs, pregnancy, drugs, alcohol, and tobacco) and safety (helmet use, sun protection).  
Will return in a year for the next well child check, sooner if needed/as below.
Acne: Mild facial acne. Plan to initiate over-the-counter benzoyl peroxide wash and follow up in 3 months if no improvement.