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.
15. I can get myself to my medical appointments. Yes No
Transitions- Managing My Own Health Care Scoring
If you answered Yes to:
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.
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.