Adolescent (age 12-17) Annual Screening Assessments
This form is an electronic adapted version of our pre-teen/teenage screening assessments. This should be completed and submitted by the patient prior to their first appointment at Pohala*. They are then to be completed every 1 calendar year thereafter until the patient turns 18 years of age. It will take approximately 10 minutes to take.
*If the patient needs assistance with reading, a parent or guardian may assist.
Note: This must be completed no earlier than 14 calendar days prior to your appointment, and no later than the morning of.
The answers you provide here are private, and will be used only in regards to your healthcare. These answers are protected under HIPAA and will remain confidential.
What is your full legal name?
What is your date of birth?
What is the date of your appointment?
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This form was created inside of Pohala Clinic.