174 Elm Street
Montpelier,Vermont 05602
Phone: 802-505-0597 Fax: 802-223-2016
Pediatric Intake Supplement
Ages 12-17
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Age
Date of Birth
*
In the PAST YEAR, have you smoked cigarettes, vaped or use other tobacco products? If yes, how often/how much?
*
In the PAST YEAR, have you have more than a few sips of beer, wine, or any drink containing alcohol? If yes, how often/how much?
*
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several Days
More than half the days
Nearly everyday
Little interest or pleasure in
doing things
Feeling down, depressed or hopeless
Is there any information about yourself or your family that you would like to add?
Signature
*
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