FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Treatment Flow Sheet: Hypertension
NAME OF YOUTH: ______________________________ DJJID #: ______________________________
FACILITY NAME: _______________________________ ALLERGIES:____________________________
Who made the diagnosis? _______________________________________________________________________________
When and where was it diagnosed? _______________________________________________________________________
If diagnosed prior to commitment, who most recently treated the condition? ________________________________________
When? ______________ Where? ________________________________________________________________
What treatment was ordered? ____________________________________________________________________
When was treatment last received? ________________________________________________________________
When were symptoms last experienced? ____________________________________________________________
Prior treatment confirmed by: Old records in chart Report from facility or MD’s office
Parent/guardian Youth’s account
Age of onset: _________
Type: _______________ Physical factors: _______________________ Psychological factors: _______________________
Visit date
Next appointment
Patient teaching
documented?
Diet restrictions?
Other restrictions?
Special needs?
Alert log listing?
Chart cover, H&P,
and Problem List
show condition
Height
Weight
Blood Pressure
Diastolic <95
consistently
Heart Rate
Abnormal heart
sounds?
T & R wnl?
Date of annual
work-up
EKG result
BMP result
Serum Cr result
Date of annual
fundoscopic exam?
Fundoscope results
ER or hospital since
last visit?
Medication
Compliant w/ tx?
FORM HS 037
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REV 10/06