F-01062 - Healthcheck Adolescent Review
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01062 (07/08)
HEALTHCHECK ADOLESCENT REVIEW
Screening Clinic Instructions: To be handed to adolescents 12 and over. After review, return to patient.
Patient Instructions: Sometimes it is easier to talk about things this way. If you wish, check YES or NO for each question and give this
paper to the nurse. If you have any questions about this, ask the nurse to help you. This form will be returned to you.
1. Do you think something is wrong with your general health?
Yes
No
2. Do you feel you have to exercise more than 1 hour every day or else you feel bad about yourself?
Yes
No
3. Are you often upset?
Yes
No
4. Do you think something is wrong with your body development?
Yes
No
5. Do you think something is wrong with your weight and have you tried to lose or gain weight?
Yes
No
If yes, how? ________________________________________________________________________
6. Is something slowing your progress in school?
Yes
No
7. Is something slowing your progress in work?
Yes
No
8. Are you having difficulties at home?
Yes
No
9. Do you have difficulty making friends when you are out?
Yes
No
10. Do you think something is wrong with your sexual feelings?
Yes
No
11. Do you think something is wrong with your heart?
Yes
No
12. Do you think something is wrong with your skin?
Yes
No
13. Do you think something is wrong with your eyes?
Yes
No
14. Do you cough much or have trouble breathing?
Yes
No
15. Are you concerned about your stomach or bowels
Yes
No
16. Do you think you have cancer?
Yes
No
If yes, where? _______________________________________________________________________
17. Does it burn when you go to the bathroom?
Yes
No
18. Do you have pain in your muscles or when you move?
Yes
No
19. Do you have questions about drinking alcohol or using other drugs?
Yes
No
20. Do you have questions about pregnancy or birth control?
Yes
No
21. Do you have questions about discharge from your sex organs or sexually transmitted diseases?
Yes
No
22. Do you have questions about masturbation or touching yourself?
Yes
No
23. If you wish, check each box that you have questions or concerns about. The clinic will be able to give you places and / or names to
contact for further questions.
Dating
School Problems
Birth Control
Pregnancy
Drugs
Abortion
Sexually Transmitted Diseases
Weight Control
MALES ONLY
24. Do you have concerns about “wet dreams”
Yes
No
25. Do you have concerns about the size of your sex organ?
Yes
No
FEMALES ONLY
26. Have you started your periods?
Yes
No
If yes, when? ________________________________________________________________
If no, then you may skip the remainder of these questions.
27. How often do you get your period? _______________________________________________
28. Do you have problems with your periods?
Yes
No
29. Do you take any medicine for your periods?
Yes
No
30. Have you ever had problems with a discharge, bleeding or anything else between your periods?
Yes
No
31. Please answer the following if you think you are pregnant?
Do you live in a house built before 1980 where there is paint peeling?
Yes
No
Do you have a hobby that includes lead bullets, lead weights for fishing or lead glass?
Yes
No
Do you eat non-food items such as clay, dirt, azarcon, Pay-loo-ah or Greta?
Yes
No
ANY OTHER COMMENTS OR QUESTIONS?
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