Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Have you been seen in an urgent care, ER, or hospital since last seen?
*
Yes
No
Please list any current healthcare providers (dermatologist, cardiologist, pulmonologist etc.):
*
What is your preferred pharmacy?
*
How many days a week do you usually exercise?
*
On days when you exercise, for how long do you exercise?
*
List all sports that you participate in:
Do you ever smoke cigarettes, vape or chew?
*
Yes
No
Do you ever drink alcohol?
*
Yes
No
Do you ever drive under the influence of alcohol or drugs?
*
Yes
No
Do you ever ride in a car with a person who has drank alcohol or done drugs in the hours prior to driving?
*
Yes
No
Do you use drugs?
*
Yes
No
Do you drink caffeinated drinks?
*
Yes
No
Do you drink energy drinks?
Yes
No
On a typical day, what do you have for breakfast?
*
On a typical day, what do you have for lunch?
*
On a typical day, what do you have for dinner?
*
Do you wear sunscreen?
*
Yes
No
Sometimes
Do you always wear a seat belt while riding in the car?
*
Yes
No
When was your most recent blood pressure check?
*
What was your blood pressure?
*
How many hours of sleep do you get each night?
*
Have you ever had sex?
*
Yes
No
If yes, birth control method used:
If yes, STD protection method used:
Do you have difficulty seeing clearly?
*
Yes
No
Do you have difficulty hearing?
*
Yes
No
Do you see a dentist at least once a year?
*
Yes
No
Do you always wear a helmet when riding bikes, 4 wheelers, snowmobiles, skiing or snowboarding?
*
Yes
No
Number of hours of gaming, YouTube, social media and TV per day:
*
Do you have friends you like being with?
*
Yes
No
Do you ever get bullied or picked on?
*
Yes
No
Does anyone ever hurt you?
*
Yes
No
Do have an adult that you could call if you found yourself with kids that were making bad choices?
*
Yes
No
What are you good at?
*
Do you like school?
*
Yes
No
Are school and learning difficult for you?
*
Yes
No
Little interest or pleasure in doing things:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep or sleeping too much:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy:
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV:
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way:
*
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Feeling nervous, anxious, or on edge:
*
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying:
*
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things:
*
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing:
*
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it's hard to sit still:
*
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable:
*
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid, as if something awful might happen:
*
Not at all
Several days
More than half the days
Nearly every day
Please list any problems, concerns or questions:
*
