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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.

  1. In general, are you happy with the way things are going for you?  oYes oSometimes oNo

  2. Do you get along with your family?   oYes oSometimes oNo

  3. Do you go to school regularly?   oYes oSometimes oNo

  4. Have your grades become worse then they used to be?   oYes oSometimes oNo

  5. Do you have at least one adult you can really talk to?    oYes oSometimes oNo

  6. Do you get some exercise at least 3 times a week?   oYes oSometimes oNo

  7. Do you feel you are about the right weight for your height?    oYes oSometimes oNo

  8. Do you ever use laxatives or throw up on purpose after eating?   oYes oSometimes oNo

  9. Do you wear a seat belt in a car/truck?   oYes oSometimes oNo

  10. Do you wear a helmet when you skateboard, bicycle, motorcycle, , snowmobile, or use an ATV?    oYes oSometimes oNo 

  1. Do you smoke cigarettes or chew tobacco? oYes oSometimes oNo

  2. Do you drink alcohol? oYes oSometimes oNo

  3. Have you tried any drugs (pot, cocaine, heroin, meth, oxycodone, etc)? oYes oSometimes o

  4. Do you - or anyone you live with - have a gun or carry a gun around? oYes oSometimes o No 

  5. Are you - or have you been - in a gang? oYes oSometimes o No

  6. Are you worried about money, a place to live, or having enough to eat? oYes oSometimes oN0

  7. Have you ever had sex (with women, or men, or both)? oYes oSometimes oNo

  8. Have you ever been tested for or diagnosed with a sexually transmitted disease (Chlamydia, gonorrhea, syphilis, HID, warts, herpes)? oYes oSometimes oNo

  9. Are you - or do you ever wonder if you are - gay, lesbian, bisexual or transgender?   oYes oSometimes oNo

  1. Are you currently, or have you ever been, bullied?   oYes oSometimes oNo

  2. Have you ever had thoughts about killing yourself?   oYes oSometimes oNo

  1. Do you feel afraid in any of your relationships? oYes  oSometimes oNo

  2. 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.


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

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Comment by shimauma on February 11, 2014 at 6:54pm

Well I guess this is what happens when gub'mint gets involved with healthcare.


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