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 live with anyone who uses tobacco or spend time in any place where people smoke? If Yes, Describe

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

Dyslipidemia

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?

For Females Only

Anemia

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

Growing and Developing

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