Young Adult (18 and over) Well Visit
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
GENERAL HEALTH
Have you had an injuries or serious illness since last visit?
*
No
Yes
Do you see a dentist regularly?
*
Yes
No
SAFETY
Do you always wear a seatbelt when you ride in a car?
*
Yes
No
When rollerblading, skateboarding, riding a bike, scooter, ATV or snowmobile, do you always wear a helmet?
*
Yes
No
Do you feel safe at school, work, and at home?
*
Yes
No
Do you own a gun or have access to one?
*
No
Yes
Do you have working smoke alarms and carbon monoxide detectors in your home?
*
Yes
No
Do you always wear sunscreen while outdoors?
*
Yes
No
ALCOHOL/TOBACCO/DRUGS
Do you smoke cigarettes, chew tobacco or vape?
*
No
Yes
Are you exposed to second hand 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
Do you ever fast vomit, or take 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
CRAFFT
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, feel better about yourself, or fit in?
*
No
Yes
Do you ever use alcohol or drugs, while you are by yourself alone?
*
No
Yes
Do you ever forget things you did while using alcohol or drugs?
*
No
Yes
Do your family or friends ever tell you that you should cut down on your drinking or drug use?
*
No
Yes
Have you ever gotten into trouble while you were using alcohol or drugs?
*
No
Yes
EMOTIONAL HEALTH
Have you ever been in trouble at school, work, or with the law?
*
No
Yes
TB (TUBERCULOSIS) RISK
Have you ever been exposed to anyone with TB disease or a positive TB skin test?
*
No
Yes
Were you born in a country with a high risk for TB (Asia, Middle East, Africa, Latin America)?
*
No
Yes
Have you lived in, working, or recently traveled to a country with a high risk for TB?
*
No
Yes
FAMILY HISTORY
Do you know your family medical history?
*
Yes
No
Has your parent or guardian had a stroke or heart problem before age 55?
*
No
Yes
Does your parent have high blood cholesterol (over 240) or take cholesterol medication?
*
No
Yes
Any other CONCERNS or TOPICS that you want to discuss with your doctor?
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SEXUALITY
How do you identify yourself?
*
Male
Female
Transgender
Are you attracted to?
*
Opposite sex
Same sex
Both
Neither
Are you now or have you 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) (check all that apply):
Opposite sex
Same sex
EMOTIONAL HEALTH
Over the past 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 that it's hard to sit still.
6. Becoming easily annoyed or irritable/
7. Feeling afraid as if something awful might happen.
Score
PHQ-9
Over the past 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 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 are a failure, have 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.
9. Thoughts that you would be better off dead or hurting yourself in some way?
Score
In the past 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 the 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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