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STAYING HEALTHY ASSESSMENT (ages 12 to 17)
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Person completing form:
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If other, please specify:
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Patient's age, as of today:
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School Attendance Regular?
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Grade in school (next grade if school is over for the year)
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Interpreter Needed? (Defaulted to No)
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If yes, what language?
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NUTRITION
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1. Do you drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt?
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2. Do you eat fruits and vegetables at least 2 times per day?
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3. Do you eat high fat foods, such as fried foods, chips, ice cream, or pizza more than once per week?
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4. Do you drink more than 1 soda can per day of juice, sports/energy, or sweetened coffee drink?
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***Clinician Use Only*** Nutritional Guidance:
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Clinician Note (include if pt. refused to answer):
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Leave "On" - Nutrition codes dropped
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PHYSICAL ACTIVITY
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5. Do you exercise or play sports most days of the week?
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6. Are you concerned about your weight?
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7. Do you watch TV or play video games less than 2 hours per day?
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***Clinician Use Only*** Physical Activity Guidance:
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Clinician Note (include if pt. refused to answer):
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Leave "On" - Physical Activity code dropped
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SAFETY
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8. Does your home have a working smoke detector?
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9. Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone?
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10. Do you always wear a seatbelt when riding in a car?
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11. Do you spend time in a home where a gun is kept?
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12. Do you spend time with anyone who carries a gun, knife, or other weapon?
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13. Do you always wear a helmet when riding a bike, skateboard, or scooter?
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14. Have you ever witnessed abuse or violence?
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15. Have you been hit, slapped, kicked, or physically hurt by someone (or have you hurt someone) in the past year?
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16. Have you ever been bullied or felt unsafe at school or in your neighborhood (or been cyber-bullied)?
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***Clinician Use Only*** Safety Guidance:
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Clinician Note (include if pt. refused to answer):
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DENTAL
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17. Do you brush and floss your teeth daily?
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***Clinician Use Only*** Dental Guidance:
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Clinician Note (include if pt. refused to answer):
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MENTAL HEALTH (PHQ-2)
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18. Do you often feel sad, down, or hopeless?
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18a. Do you have little interest or pleasure in doing things?
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If patient answers yes to either question, do PHQ-9
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TURN ON for PHQ-9 (or proceed to ***For Clinician Use Only***
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1. Feeling down, depressed, irritable, or hopeless?
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2. Little interest or pleasure in doing things?
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired, or having little energy?
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5. Poor appetite or overeating
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6. Feeling bad about yourself – or feeling that you are a failure, or that you have let yourself or your family down?
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7. Trouble concentrating on things like school work, reading, or watching TV?
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8. Moving or speaking so slowly that other people could notice or being fidgety or restless
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9. Thoughts that you would be better off dead, or of hurting yourself
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Does the patient have at least 5 of the 9 symptoms above?
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Add numbers in ( ) for PHQ9 Total Score
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PHQ-9 Score:
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Depression Severity Results
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***Clinician Use Only*** Mental Health Guidance:
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Depression Screening Status
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Clinician Note:
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ALCOHOL, TOBACCO, DRUG USE
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19. Do you spend time with anyone who smokes?
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20. Do you smoke cigarettes or chew tobacco?
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21. Do you use or sniff any substance to get high, such as marijuana, cocaine, crack, Methamphetamine (meth), ecstasy, etc.?
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22. Do you use medicines not prescribed for you?
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23. Do you drink alcohol once a week or more?
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24. If you drink alcohol, do you drink enough to get drunk or pass out?
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25. Do you have friends or family members who have a problem with drugs or alcohol?
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26. Do you drive a car after drinking, or ride in a car driven by someone who has been drinking or using drugs?
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***Clinician Use Only*** Alcohol, Tobacco, Drug Use Guidance:
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Clinician Note (include if pt. refused to answer):
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SEXUAL ISSUES
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Answers about sex and family planning cannot be shared with anyone, including your parents, without your permission.
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27. Have you ever been forced or pressured to have sex?
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28. Have you ever had sex (oral, vaginal, or anal)? If no, skip to question 35.
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29. Do you think you or your partner could have a sexually transmitted infection, such as Chlamydia, Gonorrhea, genital warts?
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30. Have you or your partner(s) had sex with other people in the past year?
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31. Have you or your partner(s) had sex without using birth control in the past year?
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32. The last time you had sex, did you use birth control?
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33. Have you or your partner(s) had sex without a condom in the past year?
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34. Did you or your partner use a condom the last time you had sex?
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35a. Do you have any questions about your sexual orientation (who you are attracted to)?
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35b. Do you have any questions about your gender identity (how you feel as a boy, girl, other gender)?
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***Clinician Use Only*** Sexual Issues Guidance:
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Clinician Note (include if pt. refused to answer):
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OTHER QUESTIONS
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36. Do you have any other questions or concerns about your health?
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If yes, please describe:
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