11-12 Year Old Well Child Visit: Patient Form

11-12 Year Old Well Child Visit: Patient Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Date *

Month Day Year
Date
Do you always wear a seat belt when you ride in a car? *

Yes No
Do you always ride in the back seat? *

Yes No
Do you always wear a helmet when roller skating, skateboarding, riding a bike, scooter, ATV, or snowmobile? *

Yes No
Do you feel safe at school, at home, and in your neighborhood? *

Yes No
Do you own a gun or have access to one? *

No Yes
Have you used a tanning bed? *

No Yes
Have you smoked cigarettes, chewed tobacco, or vaped in the past year? *

No Yes
Are you exposed to secondhand smoke? *

No Yes
Are you worried about any friends or family members and how much they drink, smoke, or use drugs? *

No Yes
During the past year, have you drunk any alcohol? *

No Yes
Have you used marijuana or any other drugs to get high? *

No Yes
Are you happy with your body? *

Yes No
Do you ever fast, vomit, or take laxatives or diet pills to control your weight? *

No Yes
Have you been in trouble at school or with the law? *

No Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
How do you identify yourself? *

Male Female Transgender Nonbinary
Do you have any questions about sex? *

No Yes
Who are you attracted to? *

Opposite sex Same sex Both Neither
Emotional Health (SCARED)

Choose the answer that seems to describe you for the last 3 months

	Not True	Somewhat True	Very True
1. I get really frightened for no reason at all
2. I am afraid to be alone in the house
3. People tell me that I worry too much
4. I am scared to go to school
5. I am shy

Score
PHQ-9

Over the Past Two Weeks, How Often Have You Been Bothered by the Following Problems (Select the Best Answer)

	Not at All	Several Days	Over Half the Days	Nearly Every Day
1. Feeling down, depressed, irritable or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep or sleeping too much?
4. Poor appetite, weight loss or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself -- or feeling that you have let yourself or your family down?
7. Trouble concentrating on things like school work, reading or watching TV?
8. Moving or speaking so slowly that people have noticed? Or the opposite; being so fidgety or restless you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?

Score
If your are experiencing these problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

Not difficult Somewhat difficult Very difficult Extremely difficult
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