Illini Pediatrics LLC, DBA Ideal Pediatrics

Guidelines for Adolescent Prevenative Services

Middle-Older Adolescent Questionnaire

Your name and date of birth: * Sex: What languages are spoken where you live? Race:

Medical History

1. Why did you come to the clinic/office today? 2. Do you have any health problems? If yes list problems here: 3. Did you have any health problems in the past 12 months? If yes list problems here: 4. Are you taking any medicine now? If yes list medicines here: 5. FOR GIRLS: Date when last period started: FOR GIRLS: Are your periods regular (monthly)? 6. FOR GIRLS: Have you had a miscarriage, an abortion, or live birth in the past 12 months?

Specific Health Issues

Please check wether you have questions or are worried about any of the following: If other please explain here:

Health Profile

These questions will help us get to know you better. Choose the answer that best describes what you feel or do. Your answers will be seen only by your health care provider and his/her assistant.

Eating/Weight

8. Are you satisfied with your eating habits? 9. Do you eat in secret? 10. Do you spend a lot of time thinking about ways to be thin? 11. In the past year have you tried to lose weight or control your weight by vomiting, taking diet pills or laxatives, or starving yourself? 12. Do you exercise or participate in sport activities that make you sweat and breathe hard for 20 minutes or more at a time at least 3 or more times during the week?

School

13. Are your grades this year worse than last year? 14. Have you either been told you have a learning problem or do you think you have a learning problem? 15. Have you been suspended from school this year?

Friends & Family

16. Do you have at least one friend who you really like and feel you can talk to? 17. Do you think that your parent(s) or guardian(s) usually listen to you and take your feelings seriously? 18. Have you ever thought seriously about running away from home?

Weapons/Violence/Safety

19. Do you or anyone you live with have a gun, rifle, or other firearm? 20. In the past year, have you carried a gun, knife, club, or other weapon for protection? 21. Have you been in a physical fight during the past 3 months? 22. Have you eve been in trouble with the law? 23. Are you worried about violence or your safety? 24. Do you usually wear a helmet when you rollerblade, skateboard, ride a bicycle, motorcycle, minibike, or ride in an all-terrain vehicle (ATV)? 25. Do you usually wear a seat belt the you ride in or drive a car, truck, or van?

Tobacco

26. Do you ever smoke cigarettes/cigars, use snuff or chew tobacco? 27. Do any of your close friends ever smoke cigarettes/cigars, use snuff or chew tobacco? 28. Does anyone you live with smoke cigarettes/cigars, use snuff or chew tobacco?

Alcohol

29. In the past month, did you get drunk or very high on beer, wine, or other alcohol? 30. In the past month, did any of your close friends get drunk or very high on beer, wine, or other alcohol? 31. Have you ever been criticized or gotten into trouble because of drinking? 32. In the past year have you used alcohol and then driven a car/truck/van/motorcycle? 33. In the past year, have you been in a car or other motor vehicle when the driver has been drinking alcohol or using drugs? 34. Does anyone in your family drink or take drugs so much that it worries you?

Drugs

35. Do you ever use marijuana or other drugs, or sniff inhalants? 36. Do any of your close friends ever use marijuana or other drugs, or sniff inhalants? 37. Do you ever used non-prescription drugs to get to sleep, stay awake, calm down, or get high? (These drugs can be bought at a store without a doctor's prescription) 38. Have you ever used steroid pill or shots without a doctor telling you to?

Development

39. Do you have any concerns or questions about the size or shape of your body, or your physical appearance? 40. Do you think you may be gay, lesbian, or bisexual? 41. Have you ever had sexual intercourse? If yes how old were you the first time? 42. Are you using a method to prevent pregnancy? If yes which type: 43. Do you and your partner(s) always use condoms when you have sex? 44. Have any of your close friends ever had sexual intercourse? 45. Have you ever been told by a doctor or nurse that you had a sexually transmitted infection or disease? 46. Have you ever been pregnant or gotten someone pregnant? 47. Would you like to receive information or supplies to prevent pregnancy or sexually transmitted infections? 48. Would you like to know how to avoid getting HIV/AIDS? 49. Have you pierced your body (not including ears) or gotten a tattoo?

Emotions

50. Have you had fun during the past two weeks? 51. During the past few weeks, have you often felt sad or down or as though you have nothing to look forward to? 52. Have you ever seriously thought about killing yourself, made a plan or actually tried to kill yourself? 53. Have you ever been physically, sexually, or emotionally abused? 54. When you get angry, do you do violent things? 55. Would you like to get counseling about something on your mind?

Special Circumstances

56. In the past year, have you been around someone with tuberculosis (TB)? 57. In the past year, have you stayed overnight in a homeless shelter, jail, or detention center? 58. Have you ever lived in foster care or a group home?

Self

59. What four words best describe you? 60. If you could change one thing about your life or yourself, what would it be? 61. What do you want to talk about today?