Adolescent Health History Ages 12-21
The adolescent or the parent/guardian can complete this form. If parent or guardian is completing, answer the questions about your child’s health history. You can skip questions if you don’t know the answer. This information will help us give you/your child better care.
Who is completing this form?
*
Student
Parent or guardian
Adolescent Medical History
How do you learn best?
Reading information
Hearing information
Pictures
Learn by doing (hands on)
How do you want to get information?
In writing
Tell me
Show me
Have you had an allergic reaction (bad effect) from any of the following:
I have no allergies that I know about
Medicines/drugs
Latex (like rubber gloves)
Eggs
Peanuts
Bee stings
Shellfish
Other
Please describe the medications/drugs you are allergic to
Please describe your allergies
Which medicines/drugs are you taking? Include non-prescription, herbs, fluoride, vitamins, and supplements
Please check any conditions or symptoms you have on the list below
Allergies (seasonal, hay, fever, etc.)
Asthma
Autoimmune disorder (Lupus, Celiac disease. juvenile arthritis, etc.)
Blood disorders (Sickle Cell Anemia, clotting problems, etc.)
Cancer
Problems since birth (genetic disorders or syndromes)
Diabetes
Heart problems (including a murmur or high blood pressure)
High cholesterol
Chest pain, difficulty breathing, wheezing, or coughing with exercise
Broken bones
Period/menstrual problems
Cavities or tooth pain/injuries
Dizziness, fainting, or heat-related illness
Headaches/migraines
Vision, hearing, or speech problems
Head injury or concussion
Seizures
Missing or damaged organs (eye, kidney, testicle)
Urinary, kidney, or testicle problems
Eating disorders (throwing up after eating, not eating enough, or eating too much)
Learning disability or special education needs (IEP or 504 plan)
Mental health condition (ADHD, anxiety, depression, etc.)
Autism Spectrum Disorder
Stomach problems
Other
Which type of cancer do you have/have you had?
Which bones have you broken?
What stomach problems have you had?
Is there a reason why the adolescent should not participate in sports or was ever refused participation for medical reasons?
No
Yes
Have you had any surgeries, major injuries, or been in the hospital overnight?
Yes
No
What surgeries or injuries have you had/why were you in the hospital overnight?
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Adolescent Oral Health
Do you go to the dentist regularly, 1x or more every year?
Yes
No
When was your last visit to the dentist?
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Family Medical History
Medical problems can run in families. Please check the boxes below to tell us about any health problems in your family.
Is your biological mother alive?
Yes
No
I don't know
What health problems does your biological mother have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
Is your biological father alive?
Yes
No
I don't know
What health problems does your biological father have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
Do you have biological siblings?
Yes
No
I don't know
What health problems do your biological siblings have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
Does anyone in your home smoke cigarettes?
Yes
No
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Health Concerns - Parent/Guardian to Complete
Yes
No
Do you have concerns about your child's health or safety that you would like to discuss?
Do you have concerns that your child may be using tobacco, alcohol, or drugs?
Do you have concerns about your child’s school work or attendance?
Does your child seem sad, worried, or depressed, or express feelings or have behaviors that seem out of the ordinary for their age?
Do you have concerns about your child’s involvement in sexual activity?
Is your family having any difficulties caring for your child?
Often true
Sometimes true
Never true
Don't know
Within the last 12 months I worried whether food would run out before I got money to buy more
Within the last 12 months the food we bought just didn't last and we didn't have money to get more
What is your housing situation today?
We have permanent housing
We do not have permanent housing, we live with others
We do not have permanent housing, we live on the street/camp/car
We do not have permanent housing, we live in a shelter
We do not have permanent housing, we live in transitional housing
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