Confidential Adolescent Health Risk Assessment
Name
First Name
Last Name
Sex
Date of Birth
-
Month
-
Day
Year
Date
1. Do you include fruits and vegetables in your diet every day?
Yes
No
2. How many days a week do you exercise?
3. Have you tried to lose weight by taking diet pills or laxatives, made yourself throw up after eating or starved yourself within the past 12 months?
Yes
No
4. Do you always wear a seat belt when riding in a car or moving vehicle?
Yes
No
5. Do you always wear a helmet when riding a bike, scooter, skateboard or rollerblades?
Yes
No
6. In the past month, have you been teased or threatened or has someone made you feel sad, scared or unsafe (on the internet, by text or in person)?
Yes
No
7. Have you ever been abused physically or emotionally or forced to take part in sexual activities?
Yes
No
8. Have you ever had any type of sex?
Yes
No
9. IF you have had sex, do you always use a method to prevent sexually transmitted infections and pregnancy (condoms, female barriers, etc)? Do NOT answer this question if you have not had sex.
Yes
No
10. Have you ever smoked cigarettes or used any form of tobacco? Have you ever juuled or vaped?
Yes
No
11. During the past 12 months did you drink any alcohol (more than a few sips)? Do not count sips of alcohol taken during family or religious events.
Yes
No
12. During the past 12 months have you smoked marijuana or hashish?
Yes
No
13. During the past 12 months have you used anything to get high? (“anything” includes illegal drugs over the counter and prescription drugs, and things that you sniff or “huff”)
Yes
No
14. Do you have any questions about abstinence (saying no to sex), condoms, birth control, HIV/AIDS or sexually transmitted infections (STI)?
Yes
No
15. Do you have problems or worries at home or school?
Yes
No
16. Is there at least one adult in your life that you trust and can talk to about any problems and worries you might have?
Yes
No
17. Have you driven a car drunk, high or while texting or ridden in a car with a driver who was?
Yes
No
18. Have you used someone else’s prescription (from a doctor or other health care provider) or nonprescription drugs to sleep, stay awake, calm down or get high?
Yes
No
19. Do you identify as homosexual, bisexual, transgender or are you questioning your sexual identity or gender identity?
Yes
No
FOR OFFICE USE ONLY:
Provider Signature:
Date:
Provider please choose:
Counseled
Needs Follow-up
No Current Risk
Referred
Submit
Should be Empty: