13-17 Year Old Well Child Check- Parent
Patient's name
*
First Name
Last Name
Patient's date of birth
*
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Has your child had any injuries or serious illnesses since the last visit?
*
No
Yes
Has there been a major change in your child's life recently (such as a change in living situation, change in daycare, move, divorce, remarriage, new job, illness, or other stressors)
*
No
Yes
Do you have concerns about your child's diet, weight, or nutrition?
*
No
Yes
Does your child see a dentist regularly?
*
Yes
No
Does your child consistently use sunscreen when outdoors?
*
Yes
No
Does your child watch more than 3 hours of screen time per day (such as TV, tablet, computer, phone)?
*
No
Yes
Has your child used a tanning bed?
*
No
Yes
Have you spoken to your child about drugs, alcohol, tobacco, and sex?
*
Yes
No
Are you concerned that your child is using drugs, alcohol, or tobacco?
*
No
Yes
Are you concerned that your child is having sex?
*
No
Yes
Does your child wear a seatbelt in the car?
*
Yes
No
Does your child always wear a helmet while using a bike, scooter, skateboard, roller skates, and skis?
*
Yes
No
Does your child know how to swim?
*
Yes
No
Do you have working smoke alarms and carbon monoxide detectors in your home?
*
Yes
No
Does anyone smoke near your child, or in your house or car?
*
No
Yes
Do you have a gun in your home?
*
No
Yes
If you have a gun in your home, is it locked?
*
N/A
Yes
No
Do you have concerns regarding conflict or violence in your home?
*
No
Yes
Do you have concerns regarding the use of drugs or alcohol by anyone caring for your child?
*
No
Yes
Do you have concerns about your child's use of internet or cell phones?
*
No
Yes
Has your child been exposed to anyone with TB (Tuberculosis) disease or a positive TB skin test?
*
No
Yes
Was your child born in a country with a high risk for TB (Asia, Middle East, Africa, Latin America)
*
No
Yes
Has your child lived in, worked in, or recently traveled to country with a high risk for TB?
*
No
Yes
Do you know your child's family medical history?
*
Yes
No
Has there been a change in your family medical history since your last visit?
*
No
Yes
Does your child have parents or grandparents who have had a stroke or heart problem before 55?
*
No
Yes
Does your child have a parent with high cholesterol (over 240), or who is taking cholesterol medication?
*
No
Yes
Has your child been in trouble at school or with the law?
*
No
Yes
Any CONCERNS or TOPICS that you want to discuss with your doctor?
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions, or learning, you can help your child get the best care possible by answering these questions. Please indicate how each of these statements best describe your child.
*
Never
Sometimes
Often
1. Feels sad, unhappy
2. Feels hopeless
3. Is down on self
4. Worries a lot
5. Seems to be having less fun
6. Fidgety, unable to set still
7. Daydreams too much
8. Distracted easily
9. Has trouble concentrating
10. Acts as if driven by a motor
11. Fights with other children
12. Does not listen to rules
13. Does not understand other people's feelings
14 Teases others
15. Blames others for his/her trouble
16. Refuses to share
17. Takes things that do not belong to him/her
Submit
PSC-17: I
PSC-17: A
PSC-17: E
PSC-17: Total
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform