Adolescent Sports Evaluation Samantha Monroe shadow health Documentation

Adolescent Sports Evaluation Samantha Monroe shadow health Documentation

Adolescent Sports Evaluation Shadow Health Documentation


Current Visit

– Height: 157.4 cm
– Weight: 49.9 kg
– BMI: 20
– Temp (<38° C): 36.6° C
– HR (60-100): 78
– RR (12-20): 16
– BP: 112/70

Documentation / Electronic Health Record

My Provider Notes

Ms. Monroe is a 13-year-old female here for a preparticipation evaluation to join the soccer team. Past Medical History: Tonsillectomy in childhood. Medications: No prescription meds, takes a multivitamin and apple cider vinegar. Nutrition: Follows Mediterranean diet, avoids sweets, processed foods, and white carbs. Skips lunch 1-2 times a week. Physical Activity: Plays soccer on weekends, wants to join the school team. Family Medical History: No genetic heart issues. Review of Systems: Various systems reviewed, no significant findings.

Model Documentation:

A 13-year-old female, Ms. Monroe, is here for her sports preparticipation evaluation to participate in soccer this year. She had her annual well visit six months ago. Her past medical history shows no current medical concerns, except for a tonsillectomy in childhood. She denies any missing organs. Presently, she is not taking any prescription medications, but she takes a daily multivitamin and consumes one tablespoon of Apple Cider Vinegar with water. There are no known medication allergies. Ms. Monroe follows a Mediterranean diet, avoids sweets, “white carbs,” and processed foods. She occasionally skips lunch 1-2 times a week for the last month. While she currently plays recreational soccer on weekends, she aspires to join her school team. In the family medical history, there is no reported history of genetic heart conditions or early cardiac death. Socially, she follows a Mediterranean diet, avoids “white carbs” and processed foods, but she feels the need to lose her baby fat to fit in and look athletic.

Review of Systems:

HEENT: Denies eye problems, vision difficulties, and hearing problems.
Cardiovascular: Denies any chest pain during exercise, history of cardiac issues, or prior cardiac tests.
Respiratory: Denies shortness of breath during exercise.
Musculoskeletal: Reports a sprained ankle at age 10 but denies any current muscle or joint injuries.
Neurological: Denies syncope with exercise but experiences intermittent dizziness 1-2 times after skipping lunch. Denies head injury, concussions, numbness, tingling, or weakness.
Integumentary: Denies rashes.
Genitourinary: Denies starting menses.


Vitals: Height 62 in., Weight 49.9 kg, BP 112/70, Temp 36.6C, HR 78, RR 16. General: Pleasant, no acute distress. HEENT: Symmetrical head, normal eyes, ears, nose, and throat. Respiratory: Lungs clear. Cardiovascular: Normal heart sounds. Abdomen: No bruit. Musculoskeletal: Normal extremities. Skin: No rash or lesions. Neuro: Alert and oriented, steady gait.


Vital signs: Length=62 in., Weight=49.9 kg, BMI=20, Blood pressure=112/70 mmHg, Temperature=36.6°C, Heart rate=78/min, Resp=16 breaths/min
General: Well-appearing 13-year-old in no acute distress. Upright posture without tension or rigidity, clothing clean and appropriate for the season.
HEENT: Symmetrical head. Eyes PERRLA, EOM intact, peripheral vision equal to examiner, vision 20/20 bilaterally.
Neck: Neck with full ROM.
Respiratory: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation.
CV: Regular rate and rhythm, S1S2 present, no murmurs, pulse present, equal bilaterally.
Abd: Abdomen aorta with no bruit noted.
MSK: Bilateral extremities symmetrical, FROM equally strength 5+ all extremities, Adam’s forward bend-equal iliac crest height, expected curvature of the spine, scapula equal height, cervical spine full range of motion, lumbar spine-full range of motion, trapezius strength +5 bilaterally.
Neuro: Alert and oriented x3, balance intact, sensation intact.
Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted. Hearing/Vision: Vision 20/20 uncorrected. Hearing intact.


– Pre-participation sports physical
– Inappropriate diet and eating habits


– Pre-participation sports physical: Clear to participate in sports
– Inappropriate diet and eating habits: Educate on healthy nutrition, discuss strategies to address shame and self-perception around eating and weight. Educate on identifying problematic eating behaviors. Follow up in 4 weeks for reevaluation.


Preparticipation physical:

  1. Clear to participate in sports Inappropriate diet and eating habits:
  2. Will provide education on healthy nutrition and the effects of nutrition on her body.
  3. Discuss the potential life-threatening problems caused by improper nutrition.
  4. Healthy diet includes 3 meals a day and healthy snack options, especially when exercising.
  5. Discuss strategies for reducing shame around eating, weight, and self-perception. Coping mechanisms around self-esteem and body image, including journaling, support groups, relaxation, stress management, positive self-talk, and affirmations.
  6. Limit media intake and refrain from watching shows on weight loss or dieting.
  7. Educate on identifying problematic eating behaviors. Anticipatory Guidance Safety: Review sports safety measures, including the female athlete triad, injury prevention, sunscreen and sun protection, diet, and nutritional supplements. Follow-up: Return to the clinic in 4 weeks to reevaluate nutrition and eating habits.