Illini Pediatrics LLC, DBA Ideal Pediatrics

Guidelines for Adolescent Prevenative Services

Younger Adolescent Questionnaire

Your name and date of birth: * What languages are spoken where you live? Are you: If other please enter here:

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? If yes list problems here: 4. Are you taking any medicine now? If yes list medicines here: 5. Have you been to the dentist in the last year? 6. Have you stayed overnight in a hospital in the last year?

7. Have you ever had any of the problems below? (check all that apply)

Allergies or hay fever Asthma Tuberculosis (TB) Seizures Cancer Diabetes 8. FOR GIRLS: Have you started having periods? FOR GIRLS: Are your periods regular (monthly)? FOR GIRLS: Date when last period started: 9. FOR GIRLS: Have you ever been pregnant?

Family Information

10. Who do you live with If other please explain: 11. Do you have older bothers or sisters who live away from home? 12. During the past year have there been any changes in your family such as: If other please explain:

Specific Health Issues

13. 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/Body

14. Do you eat fruits and vegetables every day? 15. Do you drink milk and/or eat milk products every day? 16. Do you spend a lot of time thinking about ways to be skinny? 17. Do you do things to lose weight (skip meals, take pills, starve yourself, vomit, etc)? 18. Do you work, play, or exercise enough to make you sweat or breathe hard at least 3 times a week? 19. Have you pierced your body (not including ears) or gotten a tattoo?

School

22. Are your grades this year worse than last year? 24. Have you been told you have a learning problem? 25. Have you been suspended from school this year?

Friends & Family

26. Do you know at least one person you can talk to about problems? 27. Do you think that your parent(s) or guardian(s) usually listen to you and take your feelings seriously? 30. Have you ever thought seriously about running away from home?

Weapons/Violence/Safety

31. Is there a gun, rifle, or other firearm where you live? 32. Have you ever carried a gun, knife, club, or other weapon to protect yourself? 33. Have you been in a physical fight where you or someone else got hurt? 34. Have you ever been in trouble with the police? 36. Are you worried about violence or your safety? 37. Do you usually wear a helmet and/or protective gear when you rollerblade, skateboard, or ride a bike? 38. Do you usually wear a seat belt the you ride in or drive a car, truck, or van?

Tobacco

39. Have you ever tried cigarettes or chewing tobacco? 40. Have any of your close friends ever tried cigarettes or chewing tobacco? 41. Does anyone you live with smoke cigarettes/cigars, or chew tobacco?

Alcohol

42. Have you ever tried beer, wine, or other liquor (except for religious purposes)? 43. Have any of your close friends ever tried beer, wine, or other liquor (except for religious purposes)? 44. Have you ever been in a car when the driver has been using drugs or drinking beer, wine or other liquor? 45. Does anyone in your family drink so much that it worries you?

Drugs

46. Have you ever taken things to get hight, stay awake, calm down or go to sleep? 47. Have you ever use marijuana (pot, grass, weed, reefer or blunt)? 48. Have you ever used other drugs such as cocaine, speed, LSD, mushrooms, etc? 49. Have you ever sniffed or huffed things like pain, 'white-out', glue, gasoline, etc? 50. Have any of your close friends ever used marijuana, other drugs, or done other things to get high?

Development/Relationships

52. Are you dating someone or going steady? 53. Are you thinking about having sex ("going all the way" or "doing it")? 54. Have you ever had sex? 55. Have any of your friends ever had sex? 56. Have you ever felt pressured by anyone to have sex or had sex when you did not want to? 57. Have you ever been told by a doctor or nurse that you had a sexually transmitted disease like herpes, gonorrhea, or chlamydia? 58. Would you like to receive information on abstinence ("how to say no to sex")? 59. Would you like to know how to avoid getting pregnant, getting HIV/AIDS, or getting sexually transmitted diseases?

Emotions

60. Have you done something fun during the past two weeks? 61. When you get angry, do you do violent things? 62. During the past few weeks, have you often felt sad or down or as though you have nothing to look forward to? 63. Have you ever seriously thought about killing yourself, made a plan or actually tried to kill yourself? 65. Have you ever been physically, sexually, or emotionally abused? 66. Would you like to get counseling about something that's bothering you?

Special Circumstances

67. In the past year, have you been around someone with tuberculosis (TB)? 68. In the past year, have you stayed overnight in a homeless shelter, jail, or detention center? 69. Have you ever lived in foster care or a group home?

Self

70. What two words best describe you? 71. What would you like to be when you grow up? 72. If you had 3 wishes come true, what would they be? 20. Is doing well in school important to you? 21. Is doing well in school important to your family and friends? 23. Are you getting failing grades in any subjects this year?