THE HEALTH CONNECTION
Eastern Area Health Education
East Carolina University
TeleHealth Program
Part 3 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:
FAMILY, FRIENDS, SCHOOL and COMMUNITY
Family:
1.
Have there been any changes in your family such as:
(Check all that apply)
Marriage
Serious illness
Births
Separation
Loss of job
Deaths
Divorce
Move to new house
Other
If any checked please explain
2.
Father's/Stepfathers occupation or job:
3.
Mother's/Stepmother's occupation or job:
4.
Are you worried about your parents?
No
Yes
If yes explain:
5.
How
do you
get along at home:
(1=Terrible and 10=Great)
1
2
3
4
5
6
7
8
9
10
6.
How would you
like
to get along at home:
(1=Terrible and 10=Great)
1
2
3
4
5
6
7
8
9
10
7.
If there is a difference between # 5 and #6? How do you think this could change?
8.
Have you ever run away from home overnight?
No
Yes
9.
Have you ever lived in a foster home or institution?
No
Yes
SCHOOL:
10.
What grade do you usually make in English?
11.
What grade do you usually make in Math?
12.
How many days have you been absent since August?
13.
How many days were you absent due to illness?
Give examples
14.
How
do you
get along at school?
(1=Terrible and 10=Great)
1
2
3
4
5
6
7
8
9
10
15.
How would you
like
get along at school?
(1=Terrible and 10=Great)
1
2
3
4
5
6
7
8
9
10
16.
Is there is a difference between #14 and #15? How do you think this could change?
17.
Have you ever been suspended?
No
Yes
18.
Have you ever dropped out of school?
No
Yes
19.
Do you plan to graduate from high school?
No
Yes
JOB/CAREER INFORMATION:
20.
Are you working?
No
Yes
if yes what is your job?
21.
How many hours do you work each week?
22.
What are your future career goals?
SELF and FRIENDS:
23.
On the whole, how do you like yourself?
(1=Not Much and 10=Very Much)
1
2
3
4
5
6
7
8
9
10
24.
What do you do best?
25.
If you could, what would you change about your life or yourself?
26.
Are there any habits you would like to break?
No
Yes
Explain:
27.
Do you feel people expect too much of you?
No
Yes
Explain:
28.
How well do you get along with your friends/peers?
1
2
3
4
5
6
7
8
9
10
29.
How well would you get along with your friends/peers?
1
2
3
4
5
6
7
8
9
10
30.
If there is a difference between # 28 and #29 how do you think this could change?
31.
Do you feel you have some friends you can count on?
No
Yes
32.
Have you ever felt really sad or depressed more than three days in a row?
No
Yes
33.
Have you ever thought of suicide as a solution to your problems?
No
Yes
34.
Have you ever gotten into any trouble because of your anger/temper?
No
Yes
35.
Have you been in a pushing/shoving fight in the last two years?
No
Yes
36.
Have you ever threatened or been threatened with a knife/gun/or other weapon?
No
Yes
37.
Have you ever been physically or sexually abused?
No
Yes
38.
Have you been involved in any violence in the past twelve months?
No
Yes
If Yes:
Were you injured?
No
Yes
How badly
Was the other person injured?
No
Yes
How did the fight start?
39.
Have you injured yourself, property or others while angry?
No
Yes
40.
What do you do when you feel angry?
Click submit just once. It may take a few seconds for the form to be processed.
Return To The Main Page