Teen Health Screen

Adolescent Annual Questionnaire

We ask all our adolescent patients to complete this form at least once a year, because substance use and mood can affect your health. Please ask your doctor if you have any questions. Your answers on this form will remain confidential.

Email*

Date of Birth*

S2BI Questions

In the PAST YEAR, how many times have you used:

If you answered “Never” to all three questions above, please answer only CRAFFT question #1 below. Otherwise, please continue answering all questions below.

If you answered “Never” or "Once or twice" to all questions above, please skip to CRAFFT question #1 below. Otherwise, please continue answering all questions below.

CRAFFT Questions

Mood (PHQ-9 Modified for Teens)

How often have you been bothered by each of the following symptoms during the past TWO WEEKS?

If you answered “Not at all” to both questions above, you are finished answering questions. Otherwise, please continue answering all the questions below.

Modified with permission by the GLAD-PC team from the PHQ-9 (Spitzer, Williams, & Kroenke, 1999), Revised PHQ-A (Johnson, 2002), and the CDS (DISC Development Group, 2000)

Name

This field is for validation purposes and should be left unchanged.