At this time, the provider should explain the concept of confidentiality to the adolescent and caregiver, who need to understand that questions regarding high-risk behaviors, such as sexual activity, can be discussed by the patient and clinician in confidence. Communicating this concept clearly is important for all so that the adolescent will be willing to share information. Most adolescents will not share sensitive information unless they are assured that such information is held in strictest confidence (Ehrman & Matson, 1998). Adolescents may better understand the terms “privacy” or “just between you and me” than the word “confidentiality” (Ginsburg, Menapace, & Slap, 1997). The provider must inform the adolescent and parents that the provider is obligated to inform the parents if the adolescent tells the provider of an intention to hurt himself or herself or others. The provider may find it helpful to have written pamphlets that describe the concept of confidentiality available in the waiting room.

The parent may be asked to provide information on family medical history and parts of the teen’s past medical history, of which the adolescent might not be aware. Parents also should be asked about any concerns they have regarding the adolescent’s health. The clinician can address the remainder of the history taking directly to the adolescent. Some health care settings use a written questionnaire to assess risk behaviors in adolescent patients. All questionnaires should be marked as confidential; ideally, a quiet, private area away from parents should be available for the adolescent to complete the form.

Parents who have difficulty separating from their offspring during the health visit may need to be reminded that individuation is a goal of adolescence. The health care visit is an opportunity for the teenager to practice independent interactions with an adult, whose goal is to guide the teen toward a healthy lifestyle. Most parents understand the teenager’s need for privacy and appreciate the chance for the adolescent to discuss confidential health care issues with another adult.

Laws regarding minors’ rights to confidentiality undergo continual modification. Medical conditions that may be treated without parental consent, depending on state law, include sexually transmitted diseases, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), contraception, pregnancy, abortion, sterilization, substance abuse, and mental health. Providers should become familiar with the statutes of their own state regarding confidential services for minors. One resource is a publication entitled State Minor Consent Statutes: A Summary, prepared by the National Center for Youth Law (English & Matthews, 1995).

The relationship between confidentiality and payment of services is an important consideration. A parent’s discovery of an independent, confidential visit by means of a bill or insurance statement places both teenager and provider in very awkward positions. It may be impossible for the provider to promise full confidentiality unless services are provided for free or the adolescent can pay for the services. Referrals may be necessary if a payment issue precludes the clinician from providing confidential care. The clinician should be aware of area resources (such as federally funded family planning clinics) that base sliding fee scales on the adolescent’s own income.

The review of systems (ROS) can be asked in a head-to-toe manner. Early adolescents, who are very attuned to the changes occurring in their bodies, often provide detailed and seemingly superfluous answers to ROS questions. Patience and attentive listening help the adolescent feel that the provider cares about what is happening to the teen. Sometimes questioning the early adolescent can be improved by using explanatory adverbs and adjectives. Instead of asking the 13-year-old if he or she has stomach trouble, the provider might ask more specifically: “Do you get frequent stomach aches that bother you a lot?”

The female adolescent’s ROS should include questions related to menstruation: age at menarche; frequency, length, and regularity of periods; and physical discomfort related to menstruation. An adolescent who reports dysmennorhea should be questioned as to what remedies she has tried, which remedies are beneficial, and if she misses school due to menstrual discomfort.

The ROS should include a general diet history and a review of sleep patterns. Growth requires energy and an adequate store of nutrients, yet adolescence is a time when diets are often irregular and loaded with “fast-foods” that have limited nutritional value. Screening for anorexia nervosa and bulimia nervosa also should occur at this time. The clinician should ask adolescents if they are happy with their body weight and if they have recently tried to lose weight. Females are at greater risk for eating disorders; however, some male athletes, such as wrestlers, may use drastic weight loss techniques to meet weight goals for their sport.

Adolescents also need to be screened for psychosocial problems in a standardized format. Studies have found such screening to be conducted sporadically for adolescent patients, with providers often avoiding emotionally sensitive issues (Elster, 1998). To address neglected areas, several different organizations have established guidelines for the adolescent visit. These include “Guide to Clinical Preventive Services” by the United States Preventive Services Task Force; “Guidelines for Adolescent Preventive Services” by the American Medical Association; “Age Charts for Periodic Health Examinations” by the American Academy of Family Physicians; “Bright Futures (BF): Guidelines for Health Care Supervision of Infants, Children, and Adolescents” by the Maternal and Child Health Bureau of the Health Resources and Service Administration; and “Recommendations for Pediatric Preventive Health Care” by the American Academy of Pediatrics. All these guidelines recommend screening regarding eating disorders, sexual activity, alcohol and other drug use, tobacco use, abuse, school performance, depression, and risk of suicide (Elster & Levenberg, 1997).

One method of organizing the adolescent interview to capture psychosocial data is to use the acronym HEADSSS (Reif & Elster, 1998). This is an adaptation of an acronym previously presented by Goldenring and Cohen (1988). The HEADSSS questionnaire encompasses all areas of screening recommended by the above organizations. It proceeds from less personal to more personal questions. Because many questions may be embarrassing to adolescents, it is often helpful to preface questions with a statement such as, “I know that some of these questions may be embarrassing, but I need to ask them to learn about your health.” Another way to introduce topics that are possibly threatening to the adolescent is by first asking the adolescent about the habits of peers. For example, when asking about substance use, the provider may start by stating, “A lot of teenagers experiment with drinking alcohol. Do any of your friends drink beer, wine, or other types of liquor?” After talking about friends’ habits, the adolescent may then feel more comfortable talking about himself or herself. The clinician should alter questions as necessary to obtain comfortably an accurate picture of how the adolescent is functioning within each of the psychosocial spheres designated by HEADSSS. Sample questions that could be used under each of the headings are as follows:

The provider must assess the developmental and social experience levels of the adolescent and gear questions to specific needs. For example, a 13-year-old who giggles, looks embarrassed, and responds negatively when asked about ever having dated probably will not need an in-depth sexual assessment that focuses on condom use and number of sexual partners in the last 6 months. The adolescent’s negative response would, however, leave an opening for the clinician to assess the young adolescent’s knowledge of pregnancy, to encourage abstinence, and to discuss briefly STIs and their prevention.

Important communication skills for providers to develop are the nonverbal techniques of recognizing and expressing emotions and the ability to express verbally sensitivity to the adolescent’s feelings. Additionally, bidirectional communication, direct questions about psychosocial issues, and attentive listening to the patient’s responses improve the diagnosis and management of health problems and the patient’s satisfaction (Coupey, 1997).

The adolescent physical examination can be approached in a head-to-toe manner with the exception of the genital examination, which is best left for last. Necessary tools for a complete examination include an ophthalmoscope, otoscope, blood-pressure cuff, and stethoscope. Other tools that may be needed include a scoliometer, magnifying glass, speculum, equipment for acquiring lab specimens, and a microscope. The examination is most easily accomplished with the adolescent undressed and wearing a gown. Some adolescents are very uncomfortable disrobing all at once. The clinician may allow the adolescent to stay dressed, removing one piece of clothing at a time as necessary for the examination to proceed.

Adolescents are concerned about disease transmission within the context of a physical examination. When ninth-grade students were interviewed concerning items that affected their decision to seek health care, the top two concerns were hand washing and the use of clean instruments. Students said that they wanted to see providers wash their hands and instruments removed from packaging (Ginsberg et al., 1997).