Adolescent Questionnaire
Name
Age
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School
Grade
Have you ever been in the hospital?
Yes
No
If yes,explain:
Family History
Rows
Yes
No
Allergy
Asthma
Blood Diseases
Cancer
Depression
GI Disease
Heart Disease
Hypertension
Kidney disease
Lung disease
Substance Abuse
Suicide
Other
Do you:
Rows
Yes
No
Attend school regularly?
Participate in sports?
Have a job?
Drive a car?
Wears seatbelt?
Ride a bicycle?
Wear a helmet?
Have weapons available?
Belong to a gang?
Do you have trouble with:
Rows
Yes
No
Your family?
Poor eating habits?
Wright loss?
Weight gain?
Acne?
School?
Have you ever:
Rows
Yes
No
Rode with a drunk driver?
Driven drunk?
Used alcohol?
Used marijuana?
Used cigarettes?
Used inhalants (sniffing/vanilla)?
Used cocaine/crack?
Used steroids?
Used other substances?
Been in trouble with the law?
Are you or have you been:
Rows
Yes
No
In the Past
Anxious or worried?
Depressed?
Angry/prone to outbursts?
Hopeless feeling?
Thinking of suicide?
Bored?
Excessively tired?
Sleeping poorly?
Are you or have you been:
Abused in anyway (physically or sexually)
Yes
No
Sexually active?
Yes
No
If yes, explain
Do you use contraception?
Yes
No
What kind?
Do you understand what are sexually transmitted diseases?
Yes
No
And how a person may get them?
Signature of Parent/Guardian
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: