Name_____________
Date______________
11-14 years
Parental concerns this visit: ________________________________________________________
________________________________________________________________________________
Current Medications: ________________________________________________________
Current Allergies: ___________________________________________________________
Home
Eats meals with family ___yes ___no
Has family member/adult to turn to for help ___yes ___no
Is permitted and is able to make independent decisions ___yes ___no
Eating
5 servings of fruit/vegetable ___yes ___no
Limited sweetened liquids ___yes ___no
Vitamins/Supplements __________________________________
Diet Concerns ___yes ___no
Diet comments ____________________________________________________________
Has concerns about body or appearance ___yes ___no
Education
Grade __________________
Performance Concerns ___yes ___no
Behavior/Attention concerns ___yes ___no
Homework concerns ___yes ___no
Activities
Has friends ___yes ___no
At least 1 hour of physical activity/day ___yes ___no
Screen time (except for homework) <2 hours/day ___yes ___no
Interests/participates in community activities/volunteers ___yes ___no
Activities ____________________
Drugs
Uses tobacco/alcohol/drugs ___yes ___no
Uses e-cigs ___yes ___no
Safety
Home is free of violence ___yes ___no
Uses safety belts/safety equipment ___yes ___no
Has peer relationships free of violence ___yes ___no
Sex
Has had oral sex ___yes ___no
Has had sexual intercourse (vaginal, anal) ___yes ___no
Suicidality/Mental Health
Over the last 2 weeks, how often has patient been bothered by any of the following problems?
1. Little interest or pleasure in doing things __Not at all __Several days __ More than half the days __Nearly every day
2. Feeling down, depressed, or hopeless __Not at all __Several days __More than half the days __Nearly every day
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
___Not difficult at all ___Somewhat difficult ___Very difficult ___Extremely difficult
Are you seeing a counselor/psychiatrist/psychologist? ___yes ___no
If yes, the counselor/psychiatrist/psychologist name: __________________________________
Has ways to cope with stress ___yes ___no
Displays self-confidence ___yes ___no
Has problems with sleep ___yes ___no
Gets depressed, anxious, or irritable/has mood swings ___yes ___no
Has thought about hurting self of considered suicide ___yes ___no
Additional comments: ____________________________________________________________
________________________________________________________________________________
