13-17 Year Old Well Child Visit- Patient
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
Do you eat fruits and vegetables every day?
*
Yes
No
Do you sleep 8 hours most nights?
*
Yes
No
Do you get 60 minutes of exercise on most days?
*
Yes
No
Do you always wear a seatbelt when you ride in a car?
*
Yes
No
Do you text while driving?
*
No
Yes
Do you always wear a helmet when roller skating, skateboarding, riding a bike, scooter, ATV, or snowmobile?
*
Yes
No
Do you feel safe at home and at school?
*
Yes
No
Do you own a gun or have access to one?
*
No
Yes
Have you used a tanning bed?
*
No
Yes
During the past year have you smoked cigarettes, chewed tobacco or vaped?
*
No
Yes
Are you exposed to secondhand smoke?
*
No
Yes
Are you worried about any friends or family members and how much they drink 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 taken laxatives or diet pills to control your weight?
*
No
Yes
Do you take any supplements or medicines to build muscle or improve athletic performance?
*
No
Yes
Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
*
No
Yes
Do you ever use alcohol or drugs to relax, fit in, or feel better about yourself?
*
No
Yes
Do you ever use drugs or alcohol when you're alone?
*
No
Yes
Do you ever forget things you did while using alcohol or drugs?
*
No
Yes
Did your family or friends ever tell you that you should cut down on your drinking or drug use?
*
No
Yes
Have you ever gotten in trouble while you were using alcohol or drugs?
*
No
Yes
Have you been in trouble at school or the law?
*
No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
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How do you identify yourself?
*
Male
Female
Transgender
Who are you attracted to?
*
Opposite sex
Same sex
Both
Neither
Are you now or have ever been in an abusive relationship
*
No
Yes
Do you have any questions about sex?
*
No
Yes
Have you ever had sex?
*
No
Yes
If yes, was your partner(s) (select all that apply)
Opposite sex
Same sex
Emotional Health (GAD-7)
Over the last 2 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 nervous, anxious or on edge?
2. Not being able to stop or control worrying?
3. Worrying too much about different things?
4. Trouble relaxing?
5. Being so restless it's hard to sit still?
6. Becoming easily annoyed or irritable?
7. Feeling afraid as if something awful might happen?
GAD-7 Total:
PHQ-9
Over the last 2 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 thing?
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 are a failure, having let yourself or family down?
7. Trouble concentrating on things like school work, reading or watching TV?
8. Moving or speaking so slowly that other people could have noticed? -- or the opposite - being so fidgety or restless that 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?
PHQ9 Total:
In the last year have you felt depressed or sad most days even if you felt okay sometimes?
*
No
Yes
Has there been a time in the past month when you have had serious thoughts about ending your life?
*
No
Yes
Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?
*
No
Yes
If you are experiencing any of these problems on this form, how difficult have these problems made it for you to do work, take care of things at home or get along with other people?
No difficult
Somewhat difficult
Very difficult
Extremely difficult
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