18 - 21 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. Information will not be shared with other people without your permission.

Health Screening

Do you live in your parents'/guardians' home?
Do you go to school?
Do you eat fruits and vegetables on a regular basis?
Do you drink milk or eat foods with calcium on a regular basis?
Have you seen the dentist in the last year?
Do you participate in a physical activity for an hour each day?
Do you wear a helmet when biking, skating or doing other sports?
Do you always wear a seatbelt when in a car?
Do you use a cell phone or headphones while driving?
Do you have any concerns about your vision?
Do you have any concerns about your hearing?
Do you have parents or grandparnets who have had a stroke or heart problem before the age of 55?
Do you have a parent with an elevated cholesterol level (240 mg/dL or higher) or who is taking cholesterol medication?
Do you regularly skip meals?
Do you use energy drinks?
Do you have concerns about your weight or appearance?
Are you or do you ever wonder if you are gay, lesbian, bisexual, or transgender?
Have you ever had someone at home, school or anywhere who has made you feel afraid, threathened you, or hurt you?
Are all of your relationships with girlfriends/boysfriends, friends, and family free of violence and abuse?
Are you having any problems at school or at work?
Do you or have you ever used supplements or performance enhancing drugs?
Do you smoke cigarettes or vape or juul or use chewing tabacco?
Have you ever had an alcoholic drink?
Have you ever used marijuana or any other drug to get high?
Do you now or have you ever used injectable drugs?
Have you been or are currently in a romantic relationship?
Have you ever not felt safe or respected in a relationship?
Do you have any questions about birth control or sexually transmitted infections?
Do you want to learn about emergency contraception? ( to help prevent pregnancy after unprotected sex)
Have you ever had sex (including oral,vaginal, or anal sex)?
Have you and your partner(s) ever forgotten to use a condom?
Have you been sexually active without using another type of birth control, besides condoms?
Have you ever been treated for a sexually transmitted infection?
Are you worried that your or your partner could have a sexually transmitted infection?
Do you have any pain with peeing, vaginal or penis discharge or pain with sex?
Have you have multiple partners in the past year?

Tuberculosis Screening

Were you or any household member born in, or has he or she traveled to a country where tuberculosis is common? ( This includes countries in Africa, Latin America, and Eastern Europe?
Have you had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?
Are you HIV positive?

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

Little pleasure or interest in doing things?
Feeling down, depressed or hopeless?

Growing and Developing

Check off all the items that you feel are true you:

For Females Only

Do you have excessive menstrual bleeding or other blood loss?
Does your period last more than 5 days?
Have you been sexually active AND had a late or missed period within the last 2 months?

For Males Only

Have you ever had sex with other men?
If we need talk privately after your visit, please give us the best way for us to communiate wit you.

275 SE Cabot Dr., Suite B-102 

Oak Harbor, WA 98277

360-675-5555

© 2021 Pediatric Associates of Whidbey Island  

1690 Layton Rd.

Freeland, WA 98249

360-331-1314