Transitions - Managing My Own Health Care Questionnaire

How well do I manage my own health care?

Please circle Yes or No

1. I know my height, weight, birth date, and social security number. Yes No

2. I know the name of my condition, can explain my special health care                                          

needs, and can tell you about my health status.                              Yes No

3. I know who to call in the case of an emergency.                          Yes No

4. I ask questions during my medical appointments.                        Yes No

5. I respond to questions from my health care providers.                Yes No

6. I know what kind of medical insurance I have.                             Yes No

7. I know the names of my medications and what they do.              Yes No

8. I know how to get my prescriptions refilled.                                 Yes No

9. I know where to find my medical records.                                    Yes No

10. I have discussed the use of tobacco, alcohol, and drugs with

my provider.                                                                                     Yes No

11. I have discussed sexuality issues with my provider.                  Yes No

12. I know how to get birth control and protection from sexually

transmitted diseases.                                                                       Yes No

13. I know how to schedule a medical appointment                         Yes No

14. I keep a schedule of my medical appointments on a calendar.

                                                                                                         Yes No

15. I can get myself to my medical appointments.                            Yes No

Transitions- Managing My Own Health Care Scoring

If you answered Yes to:

11-15 Statements

Super! You are already taking on adult responsibilities. You are

ready to transition your health care and should speak with your

health care providers about a transition plan.

6-10 Statements

You are on your way. You are actively taking on many

responsibilities in your health care. Pick a few more

responsibilities from the checklist to do for your next

appointment. Also, start talking about transitions with your

health care providers.

5 or Lower Statements

Now is a good time to start taking on more responsibility in your

health care. Pick one new responsibility from the checklist and

practice it at your next appointment. If you need help, ask a

friend, parent, nurse, social worker, or doctor.

Developed by Children's Hospital, Boston, as part of the Massachusetts Initiative for Youth with Disabilities (MIYD), a Healthy and

Ready to Work project of the Massachusetts Department of Public Health. MIYD is supported in part by project # H01MC00006

from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.

Children's Hospital. Division of Adolescent and Young Adult Medicine. 300 Longwood Avenue. Boston, MA 02115. (617) 355-7170.

_______________________