Adolescent Health Form

Summerwood Pediatrics

Name:

DOB:

Allergies:

Your Cell #:

Date:

Personal History:

What is your preferred name?

What grade are you in school/college?

Are you having any concerns about school: academically, socially, recreationally?

YES NO

If yes, please explain:

Do you feel safe at School?

YES NO

Do you have any concerns about being bullied in/out of school?

YES NO

If yes, please explain:

General Health:

Do you have any concerns about your health?

YES NO

Do you have any body image concerns?

YES NO

In the past year, have you tried to lose weight or control your weight by vomiting, taking diet pills, laxatives or starving yourself?

YES NO

Have you had weight loss that is NOT due to diet and exercise?

YES NO

If Surgery is select, Please explain:

Do you have any direct family with any of the following history? If yes, please indicate who (Parents, Siblings, Grandparents, Aunts/Uncles)

Headaches

Parents

Siblings

Grandparents

Aunts/Uncles

Chest pain

Parents

Siblings

Grandparents

Aunts/Uncles

Breathing Problems

Parents

Siblings

Grandparents

Aunts/Uncles

Asthma

Parents

Siblings

Grandparents

Aunts/Uncles

Curve of the spine

Parents

Siblings

Grandparents

Aunts/Uncles

Dizziness or fainting

Parents

Siblings

Grandparents

Aunts/Uncles

Joint pain

Parents

Siblings

Grandparents

Aunts/Uncles

Heart Disease

Parents

Siblings

Grandparents

Aunts/Uncles

Excessive tiredness

Parents

Siblings

Grandparents

Aunts/Uncles

Family Dynamic:

Who lives at home with you?

Is there a friend or family member whose physical or mental health worries you?

YES NO

Is there a friend or family member who has a problem w/ drugs or alcohol?

YES NO

Is there conflict or fighting, either verbal or physical in your home?

YES NO

Do you worry about your family’s relationship?

YES NO

Are you unhappy with your life?

YES NO

Do you feel unsafe at home?

YES NO

Has anyone abused you physically or verbally?

YES NO

If you answered yes to any of these questions, please explain:

Personal Safety:

Do you talk or text on the phone when you drive?

YES NO N/A

Have you ever driven under the influence of alcohol or drugs?

YES NO N/A

Have you been a passenger in a car where the driver has been under the influence of drugs/alcohol?

YES NO

Do you wear a seat belt, wear protective gear when you bike, rollerblade, drive an ATV, etc?

YES NO

Do you smoke cigarettes?

YES NO

Add new row

Do you Vape (E-cigarette)?

YES NO

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Do you drink beverages that contain alcohol?

YES NO

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Do any of your friends do drugs?

YES NO

Are you using: marijuana/edibles or anything else to get high? -Including inhalants, medications or someone else’s prescription (Over the counter or prescriptions)

YES NO

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Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?

YES NO

Do you ever use alcohol or drugs while you are by yourself, or ALONE?

YES NO

Do you FORGET things you did while using alcohol or drugs?

YES NO

Have you ever gotten into TROUBLE while you were using alcohol or drugs?

YES NO

For Females

At what age did you start your menstrual period?

When was your last period?

Do you have your period every month?

YES NO

Do you have any pain with your periods?

YES NO

If yes, how do you relieve the pain?

For females 18 years or older:

Have you ever been taught to do a self-breast exam?

YES NO

If yes, do you complete one monthly?

YES NO

For Males 18 Years or older:

Have you ever been taught to do a testicular self-exam?

YES NO

If yes, do you complete one monthly?

YES NO

Have you had recent changes in the size or shape of your testicles?

YES NO

If 13 years or older, please continue:

What Gender do you identify as

Sexual Orientation:

Straight/Heterosexual Gay/Lesbian Bisexual Do not know Something else Choose not to disclose

If something else, PEASE EXPLAIN

Do you have any questions or concerns about your sexual development?

YES NO

Are you sexually active?

YES NO

If no, are you thinking about being sexually active with someone soon?

YES NO

Have you ever felt pressured or forced into having sex with someone?

YES NO

Are you aware that some diseases and infections can be transmitted sexually?

YES NO

Do you know how to protect yourself against STDs & STIs? (Sexually transmitted diseases/infections)

YES NO

Do you want to be tested for STDs/STIs?

YES NO

Have you ever had a sexually transmitted disease? (Herpes, Chlamydia, Gonorrhea, Genital warts)

YES NO

Do you have any other questions, concerns or problems you would like to discuss with your doctor or Nurse Practitioner?

Reviewed by MD/PA/NP:

Date

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