Skip to content
Icon label

Adolescent Questionnaire

MHA Adolescent Questionnaire

Dear Parent or Guardian,

Now that your child is almost a teenager, there are some things we would like to share with you that are important to provide the best care.

Your son or daughter’s body is changing and so are his or her feelings. There are many health risks during the teenage years that we try to prevent, such as accidents, violence, unprotected sex, drug and alcohol use and stress.

It is good to stay close to your child. It is also important for you to allow them some time alone to talk about their health and changes in their bodies and lives. We encourage teenagers to share information with their parents. There are some things that your teen may rather talk about with their doctor or nurse.

Starting in the teen years we ask for more input from them about their health. As part of comprehensive health care it our practice to ask parents to wait outside for part of the visit. Teens often have questions or concerns they may feel embarrassed to talk about in front of their parents. It important to give them freedom to grow but not so much they get involved in the wrong activities.

As part of the teen health visit we use a confidential health survey*. The survey is highly recommended but is not mandatory. Its purpose is to give the doctor information to help care for your son or daughter. This survey was developed by the Adolescent Quality Work Group which included representatives from NYS Department of Health, and the American Academy of Pediatrics.

Please visit our website for more information. We will always defer to the parent’s or teen’s choice for comfort level regarding the visit and survey.


Medical Health Associates of Western New York

Adolescent Questionaire (ages 13 – 15)


Are your grades this year worse than last year?

Are you getting failing grades in any subjects this year?

Have you been told that you have a learning problem?

Friends and Family

Do you know at least one person who you can talk to about problems?

Do you think that your parent(s) or guardian(s) usually listen to you and take your feelings seriously?

Have your parents talked with you about things like alcohol, drugs, and sex?

Are you worried about problems at home or in your family?

Weapons/ Violence/ Safety

Is there a gun, rifle, or other firearm where you live?

Have you ever been in a physical fight where you or someone else got hurt?

Are you worried about violence or your safety?

Do you usually wear a helmet and/ or protective gear when you rollerblade, skateboard, or ride a bike?

Do you always wear a seatbelt when you ride in a car, truck, or van?


Have you ever tried cigarettes, vaping (e-cigs), or chewing tobacco?


Have you ever tried beer, wine, or other liquor more than a few sips (except for religious purposes)?

Have any of your close friends ever tried beer, wine, or other liquor (except for religious purposes)?

Does anyone in your family drink so much that it worries you?


Have you ever taken things to get high, stay awake, calm down, or go to sleep? (illegal drugs, over the counter or prescription drugs, or things you sniff or huff)?

Have you ever used marijuana or hashish (pot, grass, weed, reefer, or blunt)?

Have you ever sniffed or huffed things like paint, ‘white-out’, glue, gasoline, etc.?

Does anyone in your family use drugs so much that it worries you?

Development/ Relationships 

Are you dating someone or going steady?

Are you thinking about having sex (“going all the way” or “doing it”)?

Have you ever had sex?

Have you ever felt pressured by anyone to have sex or had sex when you did not want to?

Would you like to receive information on abstinence (“how to say no to sex”)?

Would you like to know how to avoid getting pregnant, getting HIV/AIDS, or getting sexually transmitted diseases?


In the past two weeks have you had little interest or pleasure in doing things?

During the past two weeks, have you felt down, depressed, or hopeless?

Have you ever seriously thought about killing yourself, made a plan, or tried to kill yourself?

Have you ever been physically, emotionally, or sexually abused?

Would you like to get counseling about something that is bothering you?


What two words best describe you?

What would you like to be when you grow up?