CBC Bright Futures Physical 18+ Patient Patient's Name* First Last Patient's Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY Please answer the following questions to the best of your ability. Note that all answers will remain confidential unless you report that someone is hurting you, or that you plan to hurt yourself or someone else.Do you have any concerns, questions, or problems that you would like to discuss?What are you most proud of about yourself?Do you have special health care needs?Have there been major changes lately in your family’s life?Have any of your relatives developed new medical problems since your last visit?Do you live with anyone who smokes or spend time in places where people smoke or use e-cigarettes?Developmental ScreeningCheck off each of the items that you feel are true for you.* I do things that help me have a healthy lifestyle, such as eating healthy foods, being physically active, and keeping myself safe. I have at least one adult in my life who I know I can go to if I need help. I have a friend or a group of friends that I feel comfortable to be around. I help others. I am able to bounce back when life doesn’t go my way. I feel hopeful and confident. I am becoming more independent and I make more of my own decisions. Risk Assessment AnemiaDoes your diet include iron rich foods, such as meat, iron-fortified cereals, or beans?* Yes No Unsure Do you eat a vegetarian diet (do not eat red meat, chicken, fish, or seafood)?* Yes No Unsure If you are a vegetarian, do you take an iron supplement?* Yes No Unsure Have you ever been diagnosed with iron deficiency anemia?* Yes No Unsure Do you or your family ever struggle to put food on the table?* Yes No Unsure For females: Do you have excessive menstrual bleeding or other blood loss?* Yes No Unsure Not applicable For females: Does your period last more than 5 days?* Yes No Unsure Not applicable DyslipidemiaDo you have parents, grandparents, or aunts or uncles who have had a stroke or heart problem before age 55 (males) or 65 (females)?* Yes No Unsure Do you have a parent with an elevated blood cholesterol level (240mg/dL or higher) or who is taking cholesterol medication?* Yes No Unsure Do you smoke cigarettes or use e-cigarettes?* Yes No Unsure Sexually Transmitted infections/HIVHave you ever had sex, including intercourse or oral sex?* Yes No Are you having unprotected sex?* Yes No Are you having sex with multiple partners or anonymous partners?* Yes No Are you or any of your past or current sexual partners bisexual?* Yes No Unsure Have you ever been treated for a sexually transmitted infection?* Yes No Have any of your past or current sex partners been infected with HIV or use injection drugs?* Yes No Unsure Do you trade sex for money or drugs or have sex partners who do?* Yes No Unsure For males: Have you ever had sex with other males?* Yes No Not Applicable Do you now use or have you ever used injection drugs?* Yes No TuberculosisWere you or any household member born in, or has he or she traveled to, a country where tuberculosis is common (this includes countries in Africa, Asia, Latin America, and Eastern Europe)?* Yes No Unsure Have you had close contact with a person who has tuberculosis disease or who has had a positive tuberculosis test result?* Yes No Unsure Are you infected with HIV?* Yes No Unsure VisionHave you ever failed a school vision screening test?* Yes No Unsure Do you have concerns about your vision?* Yes No Unsure Do you have trouble with near or far vision?* Yes No Unsure Do you tend to squint?* Yes No Unsure Healthy TeenDo you brush your teeth twice a day?* Yes No Do you floss your teeth once a day?* Yes No Do you see the dentist regularly?* Yes No Do you have trouble accessing dental care?* Yes No NutritionDo you have any concerns about your weight?* Yes No Are you currently doing anything to try to gain or lose weight?* Yes No Do you have access to healthy food options at home and school?* Yes No Do you eat fruits and vegetables every day?* Yes No Do you have milk, yogurt, cheese, or other foods that contain calcium every day?* Yes No Do you drink juice, soda, sports drinks, or energy drinks?* Yes No Do you ever skip meals?* Yes No Do you eat meals together with your family?* Yes No Physical Activity and SleepAre you physically active at least 1 hour every day? This includes running, playing sports, or doing physically active things with friends.* Yes No How much time do you spend watching TV, playing video games, or using computers, tablets, or smartphones (not counting work/school)?* Do you have a TV, computer, tablet, or smartphone in your bedroom?* Yes No Do you have a regular bedtime?* Yes No Do you have any trouble getting to sleep at night or waking up in the morning?* Yes No Living Situation and Food SecurityDo you feel safe in your living situation?* Yes No Within the past 12 months, did you worry that your food would run out before you got money to buy more?* Yes No Within the past 12 months, did the food you bought not last, and did you not have money to get more?* Yes No Transitioning to Adult Health CareDo you feel confident about your ability to begin seeing an adult medical provider?* Yes No Do you have health insurance coverage?* Yes No Do you know your medical conditions, medications, allergies, and family history?* Yes No Interpersonal ViolenceDo you get along with the people you live with?* Yes No Do you have ways that help you deal with feeling angry?* Yes No Have you been in a fight in the past 12 months?* Yes No Do you know anyone in a gang?* Yes No Do you belong to a gang?* Yes No Have you ever been hit, slapped, or physically hurt while on a date?* Yes No Have you ever been touched in a sexual way against your wishes or without your consent?* Yes No Have you ever been forced to have sexual intercourse?* Yes No Have you ever been in a relationship with a person who threatens you physically or hurts you?* Yes No Do you feel threatened by anyone?* Yes No Are you worried that you might ever hurt someone else?* Yes No Alcohol and DrugsIs there anyone in your life whose tobacco, alcohol, or drug use concerns you?* Yes No Connectedness with Family, Peers, and CommunityDo you have a close friend?* Yes No Do you get along with members of your family?* Yes No Do you have activities you like to do after school or work or on the weekends?* Yes No Do you help others out at home, at school, or in your community?* Yes No SchoolHave you graduated from high school or completed a GED?* Yes No Do you have plans for work or school?* Yes No Coping with Stress and Decision-MakingDo you feel really stressed out all the time?* Yes No Do you have strategies to reduce or relieve your stress?* Yes No Mood and Mental HealthDo you harm yourself, such as by cutting, hitting, or pinching yourself?* Yes No Do you have any questions about your gender identity?* Yes No Healthy Behavior ChoicesIf you have been in romantic relationships, have you always felt safe and respected?* Yes No Have you ever had sex, including oral, vaginal, or anal sex?* Yes No Have you had multiple partners in the past year?* Yes No Do you have both male and female partners?* Yes No Do you and your partner use condoms every time?* Yes No Do you and your partner always use another form of birth control along with a condom?* Yes No Are you aware of emergency contraception?* Yes No Do you smoke cigarettes or use e-cigarettes?* Yes No Do you chew tobacco or use other tobacco products?* Yes No Do you drink alcohol?* Yes No Have you used drugs, including marijuana, street drugs, inhalants, or steroids?* Yes No Have you ever taken prescription drugs that were not given to you for a medical condition?* Yes No SafetyDo you use earplugs or noise-cancelling headphones to protect your hearing around loud noises or at concerts?* Yes No Do you often listen to loud music?* Yes No Do you always wear a lap and shoulder seat belt?* Yes No Do you wear a helmet to protect your head when you ride a bike, a skateboard, a motorcycle, or an ATV?* Yes No Do you ever use your phone or tablet while driving, even at stop signs?* Yes No Do you have someone you can call for a ride if you feel unsafe driving yourself or riding with someone else?* Yes No Do you use sunscreen?* Yes No Do you visit tanning parlors?* Yes No Do you have access to guns?* Yes No Have you carried a weapon to school or work?* Yes No
