IS THIS HAPPENING IN YOUR SCHOOL DISTRICT???

2-8-14 Arizona Freedom Alliance

[AFA Editor: Excuse the formatting. This had to be converted from pdf for this page.]

Teen Questionnaire

In order to help you the best we can, we would like you to answer the questions below. we ask all teenagers these questions because we feel these are things that affect your health and well-being. All of the questions may not fit you. You may leave those that don't apply blank. Please answer the questions alone, away from your parents or friends, so that you can be as honest as possible.

Your answers are a confidential part of your medical record.

However, for your safety and because we are concerned about you, we are required by Jaw to share information involving physical/sexual abuse and suicide. Every situation is individual and we will always talk with you before sharing any of this information.

In general, are you happy with the way things are going for you? oYes oSometimes oNo
Do you get along with your family? oYes oSometimes oNo
Do you go to school regularly? oYes oSometimes oNo
Have your grades become worse then they used to be? oYes oSometimes oNo
Do you have at least one adult you can really talk to? oYes oSometimes oNo
Do you get some exercise at least 3 times a week? oYes oSometimes oNo
Do you feel you are about the right weight for your height? oYes oSometimes oNo
Do you ever use laxatives or throw up on purpose after eating? oYes oSometimes oNo
Do you wear a seat belt in a car/truck? oYes oSometimes oNo
Do you wear a helmet when you skateboard, bicycle, motorcycle, , snowmobile, or use an ATV? oYes oSometimes oNo

Do you smoke cigarettes or chew tobacco? oYes oSometimes oNo
Do you drink alcohol? oYes oSometimes oNo
Have you tried any drugs (pot, cocaine, heroin, meth, oxycodone, etc)? oYes oSometimes o
Do you - or anyone you live with - have a gun or carry a gun around? oYes oSometimes o No
Are you - or have you been - in a gang? oYes oSometimes o No
Are you worried about money, a place to live, or having enough to eat? oYes oSometimes oN0
Have you ever had sex (with women, or men, or both)? oYes oSometimes oNo
Have you ever been tested for or diagnosed with a sexually transmitted disease (Chlamydia, gonorrhea, syphilis, HID, warts, herpes)? oYes oSometimes oNo
Are you - or do you ever wonder if you are - gay, lesbian, bisexual or transgender? oYes oSometimes oNo

Are you currently, or have you ever been, bullied? oYes oSometimes oNo
Have you ever had thoughts about killing yourself? oYes oSometimes oNo

Do you feel afraid in any of your relationships? oYes oSometimes oNo
Have you ever been physically or sexually abused or mistreated by anyone (kicked, hit, pushed, forced or tricked into having sex, touched on your private parts)? oYes oSometimes oNo

North Scottsdale Pediatric Associates, 'P.C.

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Dear Parent of a Teenager:

Welcome to Adolescence, the transformati on from child to adult, when we transition from dependence on parents to make all of the decisions to developing trust in our children to make their own decisions- a process that, appropriately, takes years.

Here at NSPA, we have a special program for teenagers ages 13-19 to help our patients navigate these challenging times in good physical and emotional health, and to help parents understand what their teen is going through.

A lot of great things happen between the ages of 13-19- at home, at school, at work and with friends. And, as we all know, some not so great things can happen too. We are here to offer the best possible health care to your teenager.

Specifically, the transitions that occur include:

AT HOME as kids attain more independence and shift their focus from family to friends.

AT SCHOOL where they gain more independence and must learn to stay on top of their work and where peer pressure and bullying may occur

AT WORK where they learn to be accountable for their time and actions

WITH FRIENDS and key relationships as they develop the capacity for intimacy

Some important areas of teen health include:

Diet and exercise
Concerns about the family
Sexuality and sexual behavior
Safety and driving
Smoking and drugs

In order to best take care of your teenager, we offer:

Birth control

Depression
Peer pressure

Bullying

Dating and relationships

1. Education. We have health education materials for your teenager which discuss issues such as growing up, puberty, eating right, smoking and drinking, sex, acne, exercise, etc. These materials will help your teenager learn about good health and making good choices. Sometimes talking to us makes it easier for your teenager to discuss the subject at home with you.

2. Personal Health Survey. We give each of our teenagers a questionnaire to fill out about their health and their health concerns. We want them to fill out the questionnaire privately, so they can give us honest answers. This helps us focus our discussion with them.

3. Confidentiality. We believe that building trust and respecting privacy are essential to caring for teens. Therefore, we offer your teenager 'confidential' services. 'Confidential' means if a teenager tells us something,we don't tell anyone else, including their parents or school. There is an important exception to this: if we think there is a serious threat to the teenager's health, then we will tell the teen's parents (we let the teens know about this exception). We encourage teens to discuss important issues with you and are happy to help start these sometimes difficult conversations.

4. Privacy. Around the age of 12, we will make private time available during visits with the doctor. In addition, we will see a teenager by themselves if they come to our clinic for confidential services. This gives them a chance to learn how to take care of their health. And, it gives them a chance to talk to us privately, if they want to. Again, we will always encourage teens to talk to a parent about important health issues. If your teen is under the age of 18, we do need your consent for vaccines and procedures. At the age of 18, when our patients legally become adults, we have them sign a confidentiality agreement that specifies what, if any, information they wish us to release to you or anyone else, including test results.

5. Education far parents. We have information for parents about normal teen development and teen problem areas such as diet, puberty, drugs, STDs, and birth control.

We look forward to taking care of your teenager. Please feel free to talk to us about any concerns you have about your teenager. Is there anything you'd like to make sure we address today? Please tell us on the bottom of this page if you have any concerns or any topics you'd like to make sure we cover in our visit.

MAIN OffiCE • 10200 N . 92nd Street, suite 150 • Scottsdale. A.Z. 85258 • "Phone 480 86o-8488 • Fax 480-860-8498 NORTH OffiCE • 21807 N .Scottsdale Rd. • Scottsdale, A.Z- 85255 • Phone (q8ol q25-8q88 • fax (q8ol 86a-8q98 www.nspeds.com