Illini Pediatrics LLC, DBA Ideal Pediatrics

Guidelines for Adolescent Prevenative Services

THIS FORM SHOULD BE COMPLETED BY THE CHILD

Your full name: * Sex: Your Date of Birth:

Medical History

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?

Screen for Child Anxiety Related Disorders

Directions: Below is a list of sentences that describe how people feel. Reach each phrase and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for you. Then, for each sentence, fill in one circle that corresponds to the response that seems to describe you for the last 3 months.

1. When I feel frightened, it is hard to breathe 2. I get headaches when I am at school 3. I don't like to be with people I don't know well 4. I get scared if I sleep away from home 5. I worry about other people like me 6. When I get frightened, I feel like passing out 7. I am nervous 8. I follow my mother or father wherever they go 9. People tell me that I look nervous 10. I feel nervous with people I don't know well 11. I get stomachaches at school 12. When I get frightened, I feel like I am going crazy 13. I worry about sleeping alone 14. I worry about being as good as other kids 15. When I get frightened, I feel like things are not real 16. I have nightmares about something bad happening to my parents 17. I worry about going to school 18. When I get frightened, my heart beats fast 19. I get shaky 20. I have nightmares about something bad happening to me 21. I worry about things working out for me 22. When I get frightened, I sweat a lot 23. I am a worrier 24. I get really frightened for no reason at all 25. I am afraid to be alone in the house 26. It is hard for me to talk with people I don't know well 27. When I get frightened, I feel like I'm choking 28. People tell me that I worry too much 29. I don't like to be away from my family 30. I am afraid of having anxiety (or panic) attacks 31. I worry that something bad might happen to my parents 32. I feel shy with people I don't know well 33. I worry about what is going to happen in the future 34. When I get frightened, I feel like throwing up 35. I worry about how well I do things 36. I am scared to go to school 37. I worry about things that have already happened 38. When I get frightened, I feel dizzy 39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport) 40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well 41. I am shy

PHQ9

Over the last 2 weeks how often have you been bothered by any of the following problems? (please check the box that applies)

1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself--or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite--being so fidgety or restless that you have been moving around a lot more than usual 9. Thought that you would be better off dead, or of hurting yourself 10. If you checked off any problems, 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?