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Well-Care Questionnaire for teens aged 13 to 17 WORKSHEET TO BE COMPLETED BY TEEN This worksheet can give your health care team information to help you take better care of yourself. You don t have to answer any questions you don t want to. Kaiser Permanente values your privacy. Your answers will be kept confidential. Name Confidential phone number Is it okay to leave a message What are your MAIN REASONS for today s visit Physical exam Sports exam For clinic use Chief Complaint Camp exam Other...
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How to fill out well-care questionnaire
01
Read each question carefully.
02
Provide complete and accurate information.
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Answer the questions truthfully.
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Who needs well-care questionnaire?
01
Individuals who are seeking comprehensive healthcare services.
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People who want to assess their overall health and well-being.
03
Patients who require regular check-ups to monitor their health conditions.
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Healthcare professionals who need to evaluate the health status of their patients.
05
Insurance companies that require health-related information for coverage determination.
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