Adolescent Screening Form

Name

Age

Date or Birth

Grade in School

Plans after high school

Eating/Weight:

Do you have any concerns regarding your height or weight?

Yes No

Have you ever tried diet pills, laxatives, excessive exercise, vomiting or restricting your eating to lose weight?

Yes No

How many days per week do you exercise for greater than 30 minutes at a time?

Do you participate in any sports or clubs?

Yes No

If yes, please specify.

School/Home:

Who lives at home with you?

Do you attend school?

Yes No

If yes, what grades do you usually receive?

Do you feel safe at home?

Yes No

Do you feel safe at school?

Yes No

Have you or anyone in your home ever been abused, raped or assaulted?

Yes No

Are you having any problems at home, school or with friends?

Yes No

Are you having any issues with bullying? (in person or on-line)

Yes No

Have you ever been suspended or expelled from school?

Yes No

Alcohol/Drugs/Safety:

Do you drink alcohol or use any drugs (including Vaping, marijuana, cigarettes)

Yes No

Have you ever been the driver or ridden in a car with a driver who was high or drunk?

Yes No

Have your ever had a suicide attempt, or intentionally harmed yourself in any way (cutting, burning)?

Yes No

Have you been feeling sad, down, depressed or anxious about anything?

Yes No

Have you ever taken medications to help with anxiety or depression?

Yes No

Have you used anything else to get high? (Such as sniffing, huffing, prescription medication, or any other illegal drugs)

Yes No

Sex:

Has anyone ever touched you in a way that felt uncomfortable to you?

Yes No

Have you ever had sex? (oral, vaginal or anal)

Yes No

*if yes: Did you use protection?

Yes No

Do you want information about birth control?

Yes No

Have you ever questioned your sexuality or gender?

Yes No

Do you have any questions about sexually transmitted diseases?

Yes No

How do your prefer to be addressed?

He She They Other

If other, please specify.

May we share this info with your parents?

Yes No

Is there anything else you would like to talk to the doctor about during today’s visit?

Yes No

Best way to contact you?

Cell phone (call or text)

Other

for office use:

Provider reviewing form

Date reviewed

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