Illini Pediatrics LLC, DBA Ideal Pediatrics

Guidelines for Adolescent Prevenative Services

THIS FORM IS TO BE COMPLETED BY THE CHILD

Your Full name: * Your Date of birth * Are you:

Medical History

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

20. Is doing well in school important to your family and friends? 21. Is doing well in school important to you? 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?

Screen for Child Anxiety Related Disorders

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?