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

Part 2 Teen Health History - Self-Administered

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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.

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


PAST HEALTH: Infant, Toddler, Preschool & School Age Years

1. When my mother was pregnant with me she had health concerns: (check all that apply)

    nausea            fainting                     dizziness        high blood pressure    

    headaches       urinary frequency      insomnia         swollen feet    

    food cravings    other     (describe) 

2. My mother was   years of age when I was born.

3. My father was   years of age when I was born.

4. I was a premature baby or a full term baby when I was born.

5. My birth was on a   (day of week) at   (time of day)

6. I was born at Hospital, or home or

     other   (describe) 

7. My mother's labor lasted for   hours.

8. My delivery was: Normal Vaginal Delivery             Cesarean Section

       If C-S, describe reason    input type="TEXT" name="reason" size="25">

9. My birth weight was   pounds and   ounces. I was in. long

10. My parents comments about my birth:

11. I was breast-fed     bottle-fed     both.

12. As a baby, my health was: Excellent    Good     Fair     Poor.

     Describe why you selected this response.

13. Developmental Milestones... I was age ....when I had my first...

smile   tooth   baby food   cup   walk alone   permanent tooth
crawl   cruise   walk alone   tricycle   walk up stairs

table food (it was )     word (it was )

song (it was )           toy (it was )

game (it was )          friend (name) )

teacher (name)

13. What I remember most about my first day at school.



14. What I remember most about being 6 years old.



15. What I remember most about being 10 years old.



16. The changes of puberty I noticed most were:



CURRENT HEALTH

Do you have any questions or concerns about any of the following?

    Height/Weight            Diarrhea                 Constipation&

    Skin                          Acne                     Head/Headaches

    Eyes/vision                Joint pain               Mouth/teeth

    Diet/food/appetite       Ears/hearing           Swallowing

    Nose/frequent colds   Eating disorders      Neck/back

    Trouble sleeping        Nausea/vomiting      Muscle/bones

    Blood pressure          Arm/leg pain           Dizziness/passing out

    Tiredness                 Stomach pain          Chest/breathing/cough

    Heart/circulation        Muscle/bones         Frequent or painful urination

    Menstruation             Other 

ANTHROPOMETRICS

13. My current weight is lb. which is in the %

14. My current height is ft. which is in the %

15. My Body Mass Index (BMI) is which is in the %

BMI calculation: This is used to calculate your body weight by
  comparing your BMI with other teens of the same age and sex.

Click to access HF

My BMI Score and Percentile

My Height Factor HF My Weight = My BMI = HF X   Wt = My BMI is in the % ranking

16. My Vision Screening:

Near Vision		Far Vision
Left Eye	Right Eye	Left Eye	Right Eye
20/	20/	20/	20/
with without lenses		with without lenses

17. My Blood Pressure is  /  My pulse is  bpm.

18. I have teeth   fillings   cavities

     I brush my teeth times a day.   I floss my teeth times a day.

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