13 - 14 Year Well Visit: PATIENT Questionnaire

Our discussions with you are private. We hope you feel free to talk openly with us about yourself and your health. It is Washington State law that information about mental health, sex, STDs, drug and alcohol use will not be shared without your permission, unless we are concernrned that you or someone else is in danger.

6. Do you eat fruits & vegetables regularly?
7. Do you drink milk or eat foods with calcium on a regular basis?
8. Do you participate in any physical activity (may be more than 1) for at least an hour each day?
9. Do you use a helmet when biking, skating, skiing, or other sports?
10. Do you always wear a seatbelt when in the car?
11. Do you have access to a gun at home or elsewhere?
12. Is there someone at home or school or another place that has made you feel afraid or threatened you or hurt you?
13. Do you have concerns about your weight or appearance?
14. Are you or do you ever wonder if you are gay, lesbian, bisexual, or not the gender you were assigned at birth?
15. Do you drink more than 1 soda, juice or other sweetened drink each day?
16. Do you have problems stopping watching TV, playing video games, being on the computer, tablet or phone when you need to do something else?
17. Have you seen things on the internet or social media that upset you?
18. Does texting and/or social media cause more bad feelings than good among your friends?
19. Have you ever posted something or sent something by text then regretted it?
20. Do you have any problem falling or staying asleep?
21. Are you having problems in school?
23. Do you have concerns about your vision or hearing?
24. Does anyone you live with smoke cigarettes, cigars, vape, or chew tabacco?
25. Have you smoked cigarettes, e-cigarettes, vaped, juuled, or chewed tabacco?
26. Have you ever drunk more than a few sips of alcohol?
27. Have you ever taken things to t high, stay awake, calm down, or go to sleep.
28. Have you ever used marijuana or anything else to get high?
29. Have you ever used drugs: cocaine, crack, heroine, ecstasy, meth, inhalants, etc.?
30. Have you been or are currently in a romantic relationship?
31. Have you ever felt not safe or respected in a relationship.
32. Have you ever has sex (oral, vaginal, or anal sex)?
33. Do you and your partner ever forget to use a condom?
34. Have you been sexually active without using another type of birth control in addition to a condom?
35. Do you need to learn about emergency contraception?
36. Females: Have you started having a period?
37. Females: If yes: any problems with your periods?
39. Any recent changes or challenges in your life?

In the past 2 weeks, how often have you been bothered by the following problems:

41. Little pleasure or interest in doing things?
42. Feeling Down, depressed, or hopeless?
If we need to talk to you privately after your visit, please give us the best way for us to communicate with you.

275 SE Cabot Dr., Suite B-102 

Oak Harbor, WA 98277

360-675-5555

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1690 Layton Rd.

Freeland, WA 98249

360-331-1314