| Adolescent Girls (13 to 18 Years) |
| Demographic Data |
| Contraception History |
| Social History |
| Sexual History |
| Family Medical History/ Mother, Father, Sister, Brother |
| Personal Medical History |
| Menstrual History |
| Pregnancy History (if you have not ever been pregnant, skip to the next section) |
| Personality questions |
| Women's health |
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What is your complaint or problem relevant to being a woman? _________________________ Do you think there are any other issues relevant to woman? _________________________ What are the details of the issue or issues? _________________________ What should I know about you? Address Activities of everyday living Annual health assessment Assets Abilities/skills Complaint/problem Communications Duties Detention Education Emergency Contact Hospitalization Impairment Rating and Disability Determination Language Photograph Profession Referrals Survival Needs Stress Travel history What is your name? _________________________ What is your date of birth? _________________________ Where and when were you born? _________________________ What is your gender? _________________________ What is today's date? _________________________ What is your telephone number? _________________________ What is your e-mail address or fax number? _________________________ Address What is your mailing address? ________________________ ________________________ ________________________ ________________________ Where are you located now? ________________________ What was your mailing address from birth until now? _________________________ _________________________ _________________________ _________________________ Where do you live now? _________________________ How long have you lived at this address? _________________________ What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency? _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ How long do you plan to live at this address? _________________________ Activities of everyday living What is your normal day like? _________________________ What do you normally enjoy doing? _________________________ Annual health assessment When was your last annual health assessment done? _________________________ Who did your last annual health assessment? _________________________ What were the findings? _________________________ What were the recommendations? _________________________ Did the recommendations help? _________________________ Was it an annual health assessment or evaluation of a new problem? _________________________ When did you last see a medical doctor? _________________________ Did you see a medical doctor for an annual health assessment or a new problem? _________________________ What seemed to be the problem? _________________________ What was the diagnosis and treatment? _________________________ What is the name and contact information of the medical doctor who gave you this diagnosis and treatment? _________________________ Assets What are your assets? _________________________ Abilities/skills What are your abilities and skills? _________________________ Complaint/problem Do you have any complaint/problem relevant to human health care today? _________________________ If you have any complaint/problem relevant to human health care today, what are the details? _________________________ How are you feeling today? _________________________ Do you have any problems today? _________________________ What seems to be the problem? _________________________ _________________________ _________________________ _________________________ _________________________ Do you have any other problems? _________________________ Can you explain? _________________________ Communications What is the best method to communicate with you? E-mail. Fax. Telephone call. Postal mail. Communication through media. _________________________ Education What is your educational background? _________________________ What is your work experience? _________________________ Emergency Contact Do you have a guardian who can be contacted in an emergency? _________________________ What are the details of your guardian? _________________________ If there are none in Illinois, the state of Illinois should arrange a guardian. Impairment Rating and Disability Determination Health status How would you describe your health status relevant to your age? _________________________ 100% mentally fit. 100% physically fit. Do you have any problems with activities mentioned below relevant to your age? Walking Seeing Hearing Speaking Breathing Learning Working Caring for oneself (eating, dressing, toileting, etc.) Performing manual tasks Getting started after sleep Sitting Sleeping _________________________ These are basic questions. There are many more. |
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Contraception History: How old were you when you first had vaginal intercourse? _________________________ ______years old. How important is it for you to avoid pregnancy now? _________________________ Very Somewhat Not at all What birth control methods have you used in the past? _________________________ None Condoms/rubbers IUD Foam/film or jelly Birth control pills Implants under the skin Withdrawal/pulling out DepoProvera/shot Diaphragm/cervical cap Rhythm method Patch Tubal ligation/tubes tied Partner has vasectomy NuvaRing (vaginal ring) What birth control are you and your partner(s) currently using? _________________________ None Yes No Are you happy with your method? _________________________ How often do you use condoms? _________________________ Always Sometimes Never Have you ever used emergency contraception (morning after pill)? _________________________ Yes No Maybe Are you planning to get pregnant in the next two years? _________________________ Have you ever been pregnant in the past? _________________________ Are you currently breastfeeding? _________________________ Have you had problems with previous pregnancies? _________________________ How many glasses of an alcoholic beverage do you have per week? _________________________ Do you smoke cigarettes? If yes, how many cigarettes per day? _________________________ Do you use street drugs? If yes, please list: _________________________ Have you ever used injected drugs? _________________________ Have you ever shared needles? _________________________ Has anyone ever told you that you have a problem with drugs or alcohol? _________________________ Is anyone, including your partner, threatening you, causing you to be afraid, or hurting you physically? _________________________ Have you ever been pressured or forced to have sex when you did not want to? _________________________ Have you ever had a sex partner with a history of: Injected drug use Sex with men _________________________ Sexual History: The case history is essential for correct diagnosis and proper case management. When did you first have intercourse? _________________________ How old were you? _________________________ What do you understand about intercourse? _________________________ How do you feel? _________________________ Are you sexually active? _________________________ What method of contraception are you currently using? _________________________ When did you start it? _________________________ Did you have any side effects? _________________________ What contraceptive methods have you tried previously? _________________________ When did you start using that contraceptive method? _________________________ Where did you procure it? _________________________ Why did you stop it? _________________________ With how many different people have you had intercourse up to now? _________________________ How many times have you had intercourse up to now? _________________________ What was the location? _________________________ Were you raped? _________________________ Have you ever been raped? _________________________ Where you ever molested? _________________________ What do you think is the difference between rape and molestation? _________________________ What is your normal day like? _________________________ In the last 12 months... 1. ? Yes ? No Have you been sexually active? If no, skip to #6. If yes, how many sexual partners have you had? ________ Have you had sex with: ? Men ? Women ? Both 3. Have you and/or your partner(s) had: ? Oral sex ? Anal sex ? Vaginal sex 4. ? Yes ? No _________________________ Do you think that your partner has other sexual partners? _________________________ In the last 12 months have you or your sex partner(s) had any of the following: Chlamydia Trichomoniasis (Trich) Bacterial vaginosis (BV) Gonorrhea Pelvic Inflammatory Disease Syphilis Genital Herpes Genital warts Other: ________________ 7. ? Yes ? No Is there anything else about your health or sexual practices that you would like to discuss with your clinician? _________________________ IF YOU ARE UNDER 18 YEARS OF AGE Do you talk to your parents about sexuality issues? _________________________ This information is confidential and will be used by your medical provider to make sure you get proper care. Are you allergic to any medications? _________________________ Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies? _________________________ Do you have another healthcare provider? If yes, who? _________________________ Pregnancy History (if you have not ever been pregnant, skip to the next section) Have you ever been pregnant in the past? _________________________ ( if no, skip to the next section) Please list the number of the following: _____ Pregnancies _____ Live births _____ Abortions _____ Miscarriages _____ Ectopic (tubal) pregnancies _____ # of C - secti ons How long ago was your last pregnancy? _________________________ _____ month(s), _____ year(s) Are you currently breastfeeding? _________________________ Have you had problems with previous pregnancies? _________________________ Pregnancy History Do you plan to have children within the next 2 years ? _________________________ Would you like information that could help y ou to have a healthy pregnancy when the time is right for you? _________________________ How do you plan to prevent pregnancy? _________________________ Have you ever been pregnant? _________________________ Have you been pregnant within the past year? _________________________ Age at first pregnancy: ________________ Number of times pregnant: __________ Number of live births: ______________ Number of living children: ___________ Ages: _____________ Number of C - sections: ____ _______ _ Number of miscarriages: ____________ Number of abortions: _______________ Number of ectopic/tubal pregnancies: ____________ Describe any complication you had during pregnancy (high blood pressure; depression; high blood sugars)___ ________________________________ Are you breastfeeding now? ________________________________ Do you think you may be pregnant now? ________________________________ Family Medical History/ Mother, Father, Sister, Brother: Provider notes: Has anyone in your family (mother, father, brother, sister) ever had: Heart attack/disease High cholesterol Maternal DES exposure Stroke Diabetes Cancer Ovarian, breast or uterine Blood clot in legs/lungs Birth defects/genetic problems I do not know my family medical history High blood pressure Personal Medical History: Have YOU ever had problems with any of these? Check all that apply. Heart disease Sickle cell disease Gall bladder disease High blood pressure Kidney/bladder problems Eating disorder Stroke Seizures or epilepsy Cancer Diabetes Depression High cholesterol Suicidal thoughts Thyroid disease Tuberculosis (TB) Fibroids Asthma Severe headaches or Ovarian cyst/abnormality Blood clot in legs/lungs migraines Endometriosis Bleed/bruise easily Liver problems Infertility Anemia hepatitis Lupus _________________________ Have you ever been hospitalized or had any surgery? If yes, when and why? _________________________ Have you ever had a transfusion or blood exposure? _________________________ Have you been immunized against rubella? _________________________ Have you been immunized against hepatitis B? _________________________ When was your last Pap smear? _________________________ Have you ever had an abnormal Pap smear? _________________________ Have you ever had a mammogram? _________________________ If yes, when was your last one? ______________ Was it normal? _______________ Menstrual History: Age period started: __________ Periods come every _________ days and last _________ days. Periods are: Regular Irregular Painful Light Moderate Heavy Yes No Do you have bleeding or spotting in between your periods? _________________________ I HAVE OR HAVE HAD: NO YES NOW 1. List any previous surgery 2. Are you allergic to any medications? List type & reaction you have, ex: nausea, etc. 3. High blood pressure 4. Heart disease 5. Blood clots in my legs/lungs 6. Varicose veins/circulatory problem 7. Elevated cholesterol 8. Thyroid problem 9. Diabetes 10. Asthma or lung diseases 11. Liver disease, hepatitis, recent jaundice, mono 12. Gall bladder disease 13. Epilepsy, convulsions/seizures 14. A skin disorder 15. Emotional problems/d epression 16. Sickle Cell trait/disease, other anemia 17. Cancer: Type 18. Urinary problems 19. Numbness in arms or legs 20. Bowel/stomach/rectal problems 21. Do you have any risk factors for ________? For example: multiple partner s, IV drug use, unprotected sex 22. Sexually Transmitted Infections (gonorrhea, syphilis, herpes, chlamydia, warts) 23. Stroke or paralysis 24. Migraines 25. Breast cysts or lumps or disease 26. Infection in tubes, ovaries, uterus 27. I do breast self - exams regularly 28. Abnormal Pap smear 29. Female or abdominal surgery? 30. Do you smoke? Number per day______ 31. Do you use snuff? 32. Do you use alcohol? (beers/drinks per day ____ or ____ per week) 33. Do you drink and drive? 34. Do you wear seat belts? 35. Do you use bicycle or motorcycle helmets? Premarital counseling for the bride and groom How should you do a quick assessment, diagnosis, and treatment of a person reported as a human pregnancy medical emergency? Pregnancy Other |