Free Confidential Health Survey, HCF 01068M - Wisconsin


File Size: 18.8 kB
Pages: 1
Date: February 16, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCF
Word Count: 347 Words, 2,627 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F0/F01068M.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068M (07/08)

STATE OF WISCONSIN

Reprinted and adapted with permission from Memee K. Chun, M.D.

Confidential Health Survey
(To be filled in by teenager) Instructions: Completion of this form is voluntary. This questionnaire will help us get to know you better. Please answer the following questions and feel free to ask a staff member about items, which may be confusing to you. Patient Name What do you like to be called (nickname)? Why are you coming to the clinic today? On a scale of 1 to 10 how would you rate your general health? 1 Awful 2 3 4 5 6 7 8 9 10 Great Date of Birth Today's Date

Many teens and young adults have concerns about the following items. Check any box that may apply to you. trouble sleeping being tired during the day headaches stomach aches dizzy / fainting spells height or weight muscle or joint pain vision or hearing problems skin problems (acne, rashes) earaches sore throats coughing or wheezing (asthma) vomiting diarrhea pain with urination allergies / hay fever privacy friends no friends brothers / sisters parent / family grades / schools recurrent dreams or nightmares fear of unplanned pregnancy or STD's controlling your temper nothing to do your future feeling down or depressed a place to live family members drinking excess alcohol using drugs

Other, describe ___________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Check all boxes that you would like to know more about. menstruation pregnancy or having children birth control dating sexually transmitted diseases (STD's) AIDS or HIV exposure teenage body changes ways to deal with stress sexual assault or abuse physical abuse your sexual development / feelings masturbation drugs / alcohol cancer death and dying

Other, describe ___________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Now think about these lifestyle patterns which may affect your health. Are there any you would like to change? If yes, check the appropriate boxes. nutrition or diet exercise smoking / chewing tobacco sleep your response to stress school performance making and keeping friends drinking alcohol or using drugs getting along with family sexuality finding a job communication with parents and others use of seat belt / motorcycle / bike helmets