THE HEALTH CONNECTION
Eastern Area Health Education
East Carolina University
TeleHealth Program

Part 1 Teen Health History - Self-Administered

---

This information is CONFIDENTIAL. The purpose is to help you and your nurse learn about your health status. We request that you fill out the form completely (there will be three Parts over three weeks). You may skip any question that you do not want to answer. A nurse instructor will review the history and a confidential interview with a nurse will be arranged.

---

Please Enter the Following Information:
Email Address:
First: Middle: Last:

DOB : Month: Day: Year:   Name you like to be called:

Address: Street/Box: City:

State Zip:

Phone Number: Another Number:

Homeroom Teacher: Rm#:

---

HOME INFORMATION
With Whom Do You Live? (Check all that apply)

Both Natural Parents	Stepmother	Brother(s)/ages
Mother	Stepfather	Sister(s)/ages
Father	Guardian	Other
Adoptive family	Alone	Describe

Describe the Setting Where You Live (location, type residence, rooms, etc.)


HEALTH INFORMATION

Do you have a Physician?Yes No  Unsure    Name

When was the last time you saw a medical doctor and why?  

Do you have a Dentist?Yes No  Unsure    Name

When was the last time you saw a Dentist and why?  

Do you have an Eye Doctor?Yes No  Unsure    Name

Do you wear glasses or contacts?Yes No

When was your last eye examination?

Do you have any other health care providers you see?  Yes No 
If yes, why?  

How do you rate your health status?  Check the area on the scale that best describes your health.
Excellent  Very Good  Good    Fair  Poor

---

You may need assistance from a parent to complete some of this information.

1.  Are you allergic to any substances? (Check any that apply)
    Food  bee stings  medications  animals   Fair  other

2.  Are you taking any medications now?  Yes  No
     If yes, provide name of medicine and reason.
     

3.  Do you have any chronic health conditions?  Yes  No  Unsure
     If yes, please describe.
     

4.  Do you miss many days of school because of sickness?  Yes  No

5.  Date of your last tetanus (TD booster):    Unknown

6.  Have you had the Hepatitis B Vaccine?  Yes  No  Unsure

7.  Have you ever broken any bones?  Yes  No
     If yes, please describe.
     

8.  Have you ever been a patient in a hospital?  Yes  No
     If yes, please describe.
     

9.  Do your parents, grandparents, aunts, uncles, or siblings have any health problems?   Yes  No
     If yes, please describe who and what.
     

10. Family Genetic Tree or Genogram will be completed at a later date.

Return to the Main Page

---