This form is for adolescent patients to complete themselves before the check-up visit.
We look forward to seeing you at your visit.
To give you the best possible health care, we would like to know how things are going. Our discussions with you are private. Information is not shared with other people without your permission unless we are concerned that someone might be in danger. We hope you will feel free to talk openly with us.
Please complete this form and click submit. We will receive it in a safe and confidential way.
Instructions: How often have you been bothered by each of the following symptoms DURING THE PAST TWO WEEKS?
For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.
Over the last two weeks, how often have you been bothered by the following problems? For each symptom, select the answer that best describes how you have been feeling.
In the PAST YEAR, how many times have you used:
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