Adolescent Health Assessment

Adolescent Health Assessment

(Ages 12 - 17)
Name of Patient

First NameLast Name
Date of Birth

MonthDayYear
Date
Please answer these questions to help us get to know you and together we can plan the best care for you. It’s okay to skip any questions you are not comfortable answering.
I understand confidentiality (privacy) regarding my health information:

YesNo
Physical Health, Nutrition, and Activity:
Do you brush your teeth 2 times a day?

YesNo
Are there times when your family does not have enough food to eat?

YesNo
Have you tried to lose or control weight by making yourself throw up or by taking laxatives?

YesNo
How happy are you with your weight?

0

1

2

3

4

5

0 is Not at all happy, 5 is Very happy
What exercise, sport or strenuous activities do you enjoy doing?
How many hours per day do you watch TV, go on the internet or play video games?
Emotional Well Being
Who do you live with?
Is there anything at home, school or with friends that is making you feel worried, upset or stressed?

YesNo
If yes, what?
Do you have problems with sleep? (e.g., falling asleep, waking up at night or nightmares)

YesNo
Are you attracted to:

MalesFemalesBothNone
Have you ever felt uncomfortable being identified as male or female?

YesNo
Reduction
Have you had sex?

YesNo
Do you want information about how to avoid pregnancy (birth control) and/or sexually transmitted infections?

YesNo
Do you ever smoke cigarettes/cigars, vape, e-cigs, snuff or chew tobacco?

YesNo
School and Friends
I have at least one good friend or group of friends I am comfortable with

YesNo
How important is school to you? (Skip if not in school)

0

1

2

3

4

5

0 is Not important at all, 5 is Very important
In the last 30 days, how often did you skip or cut school?

More than 3 times1-3 timesNever
Safety and injury prevention
Do you always wear a seatbelt in the car?

YesNo
Does anyone bully, harass or pick on you?

YesPastNo
Do you or anyone close you have guns or weapons?

YesNo
Has anyone ever hurt, touched or treated you or anyone in your house in a way that made you feel scared or uncomfortable?

YesNo
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Adolescent Health Assessment

Physical Health, Nutrition, and Activity:

Emotional Well Being

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School and Friends

Safety and injury prevention