Transition Readiness Assessment Questionnaire
Directions to Youth and Young Adults: Please check the box that best describes your skill level in the following areas that are important for transition to adult health care. There is no right or wrong answer and your answers will remain confidential and private. Directions to Caregivers/Parents: If your youth or young adult is unable to complete the tasks below on their own, please check the box that best describes your skill level.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Managing Medications
*
Rows
No, I do not know how
No, but I want to learn
No, but I am learning to do this
Yes, I have started doing this
Yes, I always do this when I need to
1. Do you fill a prescription if you need to?
2. Do you know what to do if you are having a bad reaction to your medications?
3. Do you reorder medications before they run out?
4. Do you explain any medications (name and dose) you are taking to healthcare providers?
5. Do you speak with the pharmacist about drug interactions or other concerns related to your medications?
Appointment Keeping
*
Rows
No, I do not know how
No, but I want to learn
No, but I am learning to do this
Yes, I have started doing this
Yes, I always do this when I need to
6. Do you call the doctor's office to make an appointment?
7. Do you follow-up on any referral for tests, check-ups or labs?
8. Do you arrange for your ride to medical appointments?
9. Do you call the doctor about unusual changes in your health (For example: Allergic reactions)?
Tracking Health Issues
*
Rows
No, I do not know how
No, but I want to learn
No, but I am learning to do this
Yes, I have started doing this
Yes, I always do this when I need to
10. Do you fill out the medical history form, including a list of your allergies?
11. Do you keep a calendar or list of medical and other appointments?
12. Do you tell the doctor or nurse what you are feeling?
13. Do you contact the doctor when you have a health concern?
14. Do you make or help make medical decisions pertaining to your health?
15. Do you attend your medical appointment or part of your appointment by yourself?
Talking with Providers
*
Rows
No, I do not know how
No, but I want to learn
No, but I am learning to do this
Yes, I have started doing this
Yes, I always do this when I need to
16. Do you ask questions of your nurse or doctor about your health or health care?
17. Do you answer questions that are asked by the doctor, nurse, or clinic staff?
18. Do you ask your doctor or nurse to explain things more clearly if you do not understand their instructions to you?
19. Do you tell the doctor or nurse whether you followed their advice or recommendations?
20. Do you explain your health history to your healthcare providers (including past surgeries, allergies, medications)?
Please indicate how you feel about the following statement: How important to you is it to manage your own health care?
*
Not at all important
Not too important
Somewhat important
Important
Very important
Please indicate how you feel about the following statement: How confident do you feel about your ability to manage your own health care?
*
Not at all important
Not too important
Somewhat important
Important
Very important
What is your main diagnosis?
Submit
Managing medications
Appointment keeping
Tracking health issues
Talking with providers
Confidence and importance
Total average
Should be Empty: