Whole Child Pediatrics

Bright Futures Previsit Questionnaire 15 to 17 Year Visits

For us to provide you with the best possible health care, we would like to get to know you better and know how things are going for you. Our discussions with you are private. We hope you will feel free to talk openly with us about yourself and your health. Information is not shared with other people without your permission unless we are concerned that someone is in danger. Thank you for your time.

Child's name and date of birth *

What would you like to talk about today?

Do you have any concerns, questions, or problems that you would like to discuss today? What changes or challenges have there been at home since your last visit? Do you have any special health care needs? If Yes, Describe Do you live with anyone who uses tobacco or spend time in any place where people smoke? If Yes, Describe How many hours per day do you watch TV, play video games, and use the computer (not for schoolwork)?

We are interested in answering your questions. Please check off the boxes for the topics you would like to discuss the most today.

Your Growing and Changing Body School and Friends How You Are Feeling Healthy Behavior Choices Violence and Injuries

Questions

Vision

Do you complain that the blackboard has become difficult to see? Have you ever failed a school vision screening test? Do you hold books close to your eyes to read? Do you have trouble recognizing faces at a distance? Do you tend to squint?

Hearing

Do you have a problem hearing over the telephone? Do you have trouble following the conversation when 2 or more people are talking at the same time? Do you have trouble hearing with a noisy background? Do you find yourself asking people to repeat themselves? Do you misunderstand what others are saying and respond inappropriately?

Tuberculosis

Were you born in a country at high risk for tuberculosis (countries other than the United States, Canada, Australia, New Zealand, or Western Europe)? Have you traveled (had contact with resident populations) for longer than 1 week to a country at high risk Tuberculosis for tuberculosis? Has a family member or contact had tuberculosis or a positive tuberculin skin test? Have you ever been incarcerated (in jail)? Are you infected with HIV?

Dyslipidemia

Do you have parents or grandparents who have had a stroke or heart problem before age 55? Do you have a parent with an elevated blood cholesterol (240 mg/dL or higher) or who is taking cholesterol medication? Do you smoke cigarettes?

Anemia

Does your diet include iron-rich foods such as meat, eggs, iron-fortified cereals, or beans? Have you ever been diagnosed with iron deficiency anemia?

Alcohol or Drug Use

Have you ever had an alcoholic drink? Have you ever used marijuana or any other drug to get high?

STIs

Do you now use or have you ever used injectable drugs?

For Females Only

Anemia

Do you have excessive menstrual bleeding or other blood loss? Does your period last more than 5 days?

STIs

Have you ever had sex (including intercourse or oral sex)? (If no, skip to Growing and Developing) Have any of your past or current sex partners been infected with HIV, bisexual, or injection drug users? Have you ever been treated for a sexually transmitted infection? Are you having unprotected sex with multiple partners? Do you trade sex for money or drugs or have sex partners who do?

Cervical Dysplasia

Was your first time having sexual intercourse more than 3 years ago?

Pregnancy

Have you been sexually active without using birth control? Have you been sexually active and had a late or missed period within the last 2 months?

For Males Only

STIs

Have you ever had sex (including intercourse or oral sex)? (If no, skip to Growing and Developing) Have you ever been treated for a sexually transmitted infection? Are you having unprotected sex with multiple partners? Have you ever had sex with other men? Do you trade sex for money or drugs or have sex partners who do? Have any of your past or current sex partners been infected with HIV, bisexual, or injection drug users?

Growing and Developing

Check off all the items that you feel are true for you Describe