Adolescent Screening - Parents Questionnaire
Patient's Name
First Name
Last Name
Patient's Date of Birth
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Month
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Day
Year
Date
Today's Date
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Month
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Day
Year
Date
Do you have any concerns about your adolescent’s health?
Do you feel your adolescent eats a balanced diet?
How many days per week does your adolescent exercise? What type of activities do they do?
How is your child doing in school?
Do you have any concerns about your child’s behavior?
Submit
Should be Empty: