Well Checks - 11 to 16 Years

Please complete this pre-teen and adolescent wellness check form before your scheduled appointment with Virtual Child Health. This helps us review health, wellbeing, school life, development, and any concerns you or your child would like to discuss during the consultation.

If there are immediate safety concerns, including thoughts of self-harm, suicidal thoughts, severe distress, difficulty breathing, or any other medical emergency, seek urgent emergency care immediately.

Parent or guardian details

Parent or guardian full name*

Address where the young person will be during the visit*

Young person details

Young person's full name*

Telehealth consent and confidentiality

I consent to a video telehealth visit for this young person. I understand the limits of telehealth, that some assessments and any vaccines or tests may require an in-person visit, that the clinician may recommend urgent in-person care if needed, and that privacy will be protected as far as possible.

I understand that part of the consultation may be offered privately to the young person, where appropriate and in line with local law and clinical guidance.

Will the parent or guardian step out for part of the visit if clinically appropriate?*

Please selectYesNoUnsure

Does the young person prefer the parent or guardian to stay for the whole visit?

Please selectYesNoNot sure yet

Previsit history

Any concerns about mood, stress, anxiety, confidence, or emotional wellbeing?

Any concerns about school, friendships, behaviour, attention, or social life?

Any long-term health conditions or relevant medical history?

Would you prefer sensitive topics such as sexual health, substance use, or emotional wellbeing to be discussed privately during the consultation?

Please selectYesNoPrefer to decide during the visit

Safety questions

Has the young person had any recent sadness, loss of interest, thoughts of self-harm, or thoughts of harming themselves?

Please selectNoYesPrefer to discuss privately during the visit

Has there been any tobacco, vaping, alcohol, or substance use in the last 12 months?

Please selectNoYesPrefer to discuss privately during the visit

What concerns would you like addressed during this visit?*

Screeners

I understand that a depression questionnaire, such as PHQ-A or PHQ-9 Teen, may need to be completed if requested or provided before the visit.

I understand that an anxiety questionnaire, such as GAD-7, may need to be completed if requested or provided before the visit.

I understand that a substance use screener, such as CRAFFT, may need to be completed if requested or provided before the visit.

Have you completed the relevant screener(s), if provided?

Please selectYesNoNot yet sent to me

Visit preparation

Please confirm you will try to have these ready for the visit

A quiet private room for at least part of the visitPhone or device fully chargedAny medication list if relevantAny recent measurements or health records if availableParent or guardian available at the start of the consultation

Optional: is there anything specific you would like the clinician to focus on, such as sleep, school stress, friendships, mood, puberty, confidence, or a health condition review?

Consents

I confirm that I am the parent or legal guardian of this young person, or I have authority to complete this form and arrange this appointment on their behalf.

I consent to Virtual Child Health storing and processing the information submitted in order to respond to my enquiry, arrange the appointment, and document the visit in the medical record in line with the clinic privacy policy.

If the young person is in immediate danger, has active suicidal intent, is severely distressed, has difficulty breathing, has a seizure, or has any other medical or mental health emergency, contact local emergency services immediately.