Form #1 Form #1 RAAPS Questionnaire

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ADOLESCENT HEALTH RISK PROFILE
Name:
Birthdate:

Insurance:

Sex:
Ethnicity/Race:

Reg #:

Your responses will be kept confidential to the extent permitted by law, including AHRQ's confidentiality statue, 42 USC 299c-3 (c)

Office Use Only

1. In the past 12 months, have you tried to lose weight by taking diet pills or
laxatives, making yourself vomit (throw up) after eating, or starving yourself?

No

Yes

2. Do you eat some fruits and vegetables every day?

Yes

No

3. Do you exercise (run, dance, swim, bike, play basketball, etc)
for at least 60 mins, 3 or more days a week?

Yes

No

4. Do you always wear a lap/seat belt when driving or riding
in a car, truck, or van?

Yes

No

5. Do you always wear a helmet when rollerblading,biking,or skateboarding?

Yes

No

6. During the past month, have you been threatened, teased, or hurt by someone (on the
internet, by text, or in person) or has anyone made you feel sad, unsafe, or afraid? No

Yes

7. Has anyone ever abused you physically (hit, slapped, kicked), emotionally
(threatened or made you feel afraid) or forced you to have sex or be involved
in sexual activities when you didn’t want to?

No

Yes

8. Have you ever carried a weapon (gun, knife, club, etc.) to protect yourself?

No

Yes

9. In the past 3 months, have you smoked cigarettes or any other form of
tobacco (black and mild, hookah, etc) or chewed/used smokeless tobacco?

No

Yes

10. In the past 12 months, have you driven a car drunk, high, or while texting or
ridden in a car with a driver who was?

No

Yes

11. In the past 3 months, have you drunk any alcohol (beer, wine coolers, liquor, etc)
other than a few sips?
No

Yes

12. In the past 12 months, have you smoked marijuana, used other street drugs,
steroids, or sniffed inhalants (“huffed” household products)?

No

Yes

13. In the past 12 months, have you used someone else’s prescription (from
a doctor or other health care provider) or nonprescription (from a store)
drugs to sleep, stay awake, calm down or get high?

No

Yes

14. Have you ever had any type of sex (vaginal, anal or oral sex)?

No

Yes

15. Have you ever been attracted to the same sex (girl to girl / guy to guy)
or do you feel that you are gay, lesbian, or bisexual?

No

Yes

16. If you have had sex, do you always use a method to prevent sexually transmitted
infections and pregnancy (condoms, female barriers, etc)?

Yes

No

17. Do you have questions about abstinence (saying no to sex), condoms,
birth control, HIV/AIDS, or sexually transmitted infections (STI)?

No

Yes

18. During the past month, did you often feel very sad or down as though
you had nothing to look forward to?

No

Yes

19. Do you have any serious problems or worries at home or at school?

No

Yes

20. Have you ever seriously thought about killing yourself, tried to
kill yourself, or have you purposely cut, burned or otherwise hurt yourself?

No

Yes

21. Do you have at least one adult in your life that you can talk to about any
problems or worries?

Yes

No

Public reporting burden for this collection of information is estimated to average 12 minutes per response, the estimated time required to
complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Form Approved: OMB Number 0935-XXXX Exp. Date xx/xx/20xx. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports
Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.