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🩺 ADOLESCENT HISTORY TAKING PROFORMA

Community Medicine (Viva-Ready, Complete Format)

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PRELIMINARY / BEFORE YOU BEGIN

Establish rapport first. Introduce yourself. Explain confidentiality and its limits (you will break it only if there is risk to life). Always ask the parent/guardian to step out so the adolescent speaks freely. Use open-ended, non-judgmental, gender-neutral language.

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A. BIODATA / DEMOGRAPHIC DETAILS

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B. CHIEF COMPLAINT(S)

1. ........................................................ since ..........
2. ........................................................ since ..........
3. ........................................................ since ..........

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C. HISTORY OF PRESENT ILLNESS (HOPI)

• Site
• Onset (sudden/gradual)
• Character
• Radiation
• Associating symptoms
• Timing (continuous/intermittent)
• Exacerbating and relieving factors
• Severity (scale 1-10)

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D. PAST HISTORY

• Previous similar episodes
• Hospitalizations / surgeries
• Known chronic illness (asthma, diabetes, epilepsy, rheumatic fever, hypertension, sickle cell, thalassemia)
• Significant childhood illnesses (measles, chickenpox, TB, jaundice, typhoid)
• Allergies (drug / food / environmental): Yes / No (specify)
• Accidents / injuries / fractures

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E. BIRTH AND DEVELOPMENTAL HISTORY

• Type of birth: Normal vaginal / LSCS / Instrumental
• Birth weight (if known): ......... kg
• Neonatal complications: Yes / No
• Developmental milestones: Met on time / Delayed (specify domain)
• School readiness: Normal / Delayed

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F. IMMUNIZATION HISTORY

Viva point: Under RKSK/NHM, tetanus toxoid (Td) booster is given to adolescents at Class 5 and Class 10. HPV vaccine has been added to India's national program for girls 9-14 years.

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G. FAMILY HISTORY

• Father's age, occupation, health status
• Mother's age, occupation, health status
• Number of siblings (brothers/sisters), any illnesses
• Consanguineous marriage: Yes / No
• Family history of TB, diabetes, hypertension, mental illness, epilepsy, cancer, genetic disorders, substance use
• Any deaths in family (age and cause)

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H. NUTRITIONAL HISTORY

• Breakfast:
• Mid-morning snack:
• Lunch:
• Evening snack:
• Dinner:

• Number of meals per day
• Vegetarian / Non-vegetarian / Vegan
• Consumption of junk food, fast food, carbonated drinks, energy drinks
• Skipping meals (especially breakfast)
• Consumption of iron-rich foods (green leafy vegetables, meat, lentils)
• Milk/dairy intake (calcium for bone density)
• Screen-associated eating (eating while on phone/TV)
• Eating disorders: Any history of avoiding food for weight loss, binge eating, vomiting after meals, excessive dieting (screen for anorexia/bulimia)

• Height: ......... cm | Weight: ......... kg
• BMI: ......... kg/m²
• BMI-for-age interpretation (using WHO/IAP growth charts)
• Mid-upper arm circumference (MUAC) if applicable
• Signs of anemia (pallor of conjunctiva, nails, tongue)

Viva point: Nutritional anemia (iron deficiency) is the most common nutritional problem in Indian adolescents, especially girls. Weekly Iron and Folic Acid Supplementation (WIFS) is given under RKSK - 1 tablet weekly (100 mg elemental iron + 500 mcg folic acid).

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I. MENSTRUAL HISTORY (for female adolescents)

• Age at menarche: ......... years
• Cycle: Regular / Irregular
• Duration: ......... days | Frequency: every ......... days
• Flow: Normal / Heavy / Scanty
• Dysmenorrhea: Yes / No (primary/secondary)
• Last menstrual period (LMP): ..........
• Intermenstrual bleeding / spotting: Yes / No
• Premenstrual symptoms: Yes / No
• Any vaginal discharge: Yes / No (color, odor)
• Pregnancy: Never / Past / Current (to be asked sensitively and in private)

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J. PSYCHOSOCIAL HISTORY - THE HEEADSSS SCREEN

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H - HOME

• Who do you live with? (parents/one parent/relatives/hostel)
• How is your relationship with family members?
• Any recent changes at home (separation, divorce, death, financial stress)?
• Do you feel safe at home?
• Any domestic violence or abuse at home?

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E - EDUCATION / EMPLOYMENT

• Which class/grade are you in?
• How are your grades? (improving/declining/consistent)
• Any recent drop in academic performance?
• Do you enjoy school? Any subjects you particularly like/dislike?
• Do you have friends at school?
• Any bullying or teasing at school?
• Truancy or school dropout: Yes / No
• Future plans / career aspirations?

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E - EATING

• Are you happy with your weight/body?
• Do you think you are too fat or too thin?
• Have you ever tried to lose weight - dieting, fasting, laxatives, induced vomiting?
• Do you have good appetite?
• (Screen for anorexia nervosa, bulimia nervosa, binge eating disorder)

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A - ACTIVITIES

• What do you do after school/college?
• Hobbies, sports, outdoor activities
• Screen time per day (mobile/TV/internet/gaming): ......... hours
• Social media use (platforms): Facebook / Instagram / YouTube / TikTok / Other
• Sleep pattern: bedtime ......... waking time ......... Total sleep: ......... hours
• Any change in sleep pattern (insomnia, hypersomnia)
• Do you have a close friend or a "best friend"?
• Religious/community activities

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D - DRUGS, TOBACCO, ALCOHOL

• Do any of your friends smoke, drink, or use drugs? (start indirect - less threatening)
• Have you ever tried cigarettes / bidis / hookah?
• Have you ever tried alcohol? How often?
• Have you ever used cannabis / gutka / pan masala / tobacco chewing?
• Any prescription drug misuse (sleeping tablets, painkillers, cough syrup)
• Any inhalant / solvent / glue sniffing?
• Have you ever driven or ridden with someone who was drunk/high?

CRAFFT Screen (2+ YES = significant problem):

• Car - ridden in a car driven by someone high/drunk?
• Relax - use substances to relax or fit in?
• Alone - use substances alone?
• Forget - forget things done while using substances?
• Family/Friends - told to cut down?
• Trouble - gotten into trouble while using substances?

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S - SEXUALITY

• Have you ever dated anyone?
• Are you attracted to boys, girls, or both? (gender-neutral questioning)
• Are you sexually active? (Yes / No / Prefer not to say)
• If yes: Age at first sexual intercourse, number of partners
• Contraceptive use: Condom / OCP / None
• History of STI: Yes / No
• HIV testing: Done / Not done
• Ever been forced to do something sexual against your will? (screen for sexual abuse)
• Any pregnancy history (if female, asked privately)

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S - SUICIDE / MENTAL HEALTH / SELF-HARM

• How is your mood most of the time?
• Do you often feel sad, empty, or hopeless?
• Have you lost interest in things you used to enjoy?
• Do you feel lonely a lot?
• Have you ever felt that life is not worth living?
• Have you ever thought of hurting or killing yourself? (suicidal ideation)
• Have you ever made any attempt? (suicidal attempt history)
• Do you ever cut yourself or hurt yourself on purpose? (NSSI - Non-Suicidal Self Injury)
• Have you ever run away from home?

PHQ-A (Patient Health Questionnaire for Adolescents) can be used for formal depression screening.

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S - SAFETY

• Do you wear a seatbelt in cars / helmet on two-wheelers?
• Have you been in any fights recently?
• Have you ever been physically hurt by someone?
• Do you or anyone at home carry a weapon?
• Do you feel safe in your neighborhood/school?
• Internet safety: Cyberbullying, online harassment, sharing personal information/photos

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K. SOCIOECONOMIC AND ENVIRONMENTAL HISTORY

• Type of house: Pucca / Semi-pucca / Kutcha
• Number of rooms: ......... | Number of family members: .........
• Overcrowding: Yes / No (>2 persons/room = overcrowded by NHB standards)
• Source of drinking water: Tap / Well / Hand pump / River / Packaged
• Water purification method: Boiling / Filter / Chlorination / None
• Toilet facility: In house / Community / Open defecation
• Solid waste disposal: Dustbin / Open dumping
• Presence of vectors (mosquitoes, rats, cockroaches): Yes / No
• Proximity to industries / garbage dumps / water bodies
• Cooking fuel: LPG / Kerosene / Wood / Biomass (screen for indoor air pollution)
• Monthly family income: Rs. ..........
• Socioeconomic class (Kuppuswamy/BG Prasad scale): Class I / II / III / IV / V

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L. PERSONAL HISTORY

• Tobacco: Yes / No | Type: ......... | Duration: ......... | Quantity/day: .........
• Alcohol: Yes / No | Frequency: ......... | Quantity: .........
• Drug use: Yes / No (as above in HEEADSSS D domain)
• Sleep: ......... hours/day | Quality: Good / Poor
• Exercise / physical activity: Type ......... | Frequency ......... | Duration .........
• Dental hygiene: Brush twice daily / Once / Rarely
• Menstrual hygiene (for girls): Type of absorbent used, frequency of change, disposal method
• Screen time: ......... hours/day

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M. REVIEW OF SYSTEMS (SYSTEMIC ENQUIRY)

• CNS: Headache, seizures, vision changes, hearing problems, memory issues
• CVS: Palpitations, chest pain, breathlessness, syncope
• Respiratory: Cough, breathlessness, wheezing (screen for asthma - very common in adolescents)
• GIT: Abdominal pain, nausea, vomiting, altered bowel habits, jaundice
• Genitourinary: Dysuria, frequency, discharge
• MSK: Joint pain/swelling, back pain (carry heavy school bags?), scoliosis
• Skin: Acne, rashes, unusual pigmentation, self-injury marks
• Endocrine: Polyuria, polydipsia, weight changes, thyroid symptoms
• Psychiatric: Sleep, mood, anxiety, concentration/attention (screen for ADHD)

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N. GROWTH AND PUBERTY ASSESSMENT

• Age at thelarche (girls): ......... years (normal: 8-13 years)
• Age at menarche (girls): ......... years (normal: 10-16 years)
• Age of testicular enlargement (boys): ......... years (normal: 9-14 years)
• Height velocity: Adequate / Reduced
• Growth spurt: Occurred / Not yet

Viva point: WHO defines adolescence as 10-19 years. The peak height velocity (PHV) in girls is around 12 years, and in boys around 14 years.

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O. SUMMARY STATEMENT (FOR VIVA PRESENTATION)

"This is [name], a [age]-year-old [sex] student studying in [class], from a [nuclear/joint] [socioeconomic class] family, residing in [urban/rural/peri-urban] area, presenting with [chief complaint] of [duration]. Relevant positives include [key findings]. Relevant negatives include [key negatives]. Immunization history is [complete/incomplete]. Nutritional status is [normal/malnourished/obese]. HEEADSSS screen is [normal/abnormal - specify]. Pubertal development is at Tanner stage [X], which is [appropriate/delayed/precocious] for age."

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P. INDIA-SPECIFIC PROGRAMMES TO KNOW (Viva Scoring Points)

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Q. COMMON ADOLESCENT HEALTH PROBLEMS (Know for Viva)

1. Nutritional: Iron deficiency anemia, obesity, eating disorders
2. Reproductive: Dysmenorrhea, PCOD, STIs, teenage pregnancy
3. Mental health: Depression, anxiety, suicidal ideation, self-harm, ADHD
4. Substance use: Tobacco, alcohol, cannabis
5. Injuries: Road traffic accidents (leading cause of death in adolescents globally)
6. Infections: Tuberculosis, typhoid, STIs, hepatitis B
7. Non-communicable: Hypertension, type 2 diabetes (rising in urban adolescents), asthma
8. Dermatological: Acne vulgaris (most universal; affects 85% of adolescents)
9. Orthopedic: Scoliosis, Osgood-Schlatter disease, overuse injuries
10. Psychosocial: Bullying, cyberbullying, gender identity issues

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QUICK VIVA REVISION TABLE

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• Park's Textbook of Preventive and Social Medicine - Adolescent Health chapter
• Goldman-Cecil Medicine (International Ed.) - Components of Adolescent Care Health Visit, p. 231
• HEADSSS Assessment - TeachMePaediatrics
• HEADSS: The "Review of Systems" for Adolescents - AMA Journal of Ethics

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