Teen (age 15-17) Annual Screening Assessments and additional Medical History
This form is an electronic adapted version of our pre-teen/teenage screening assessments. It also includes questions about your reproductive health. Lastly, there is a form to authorize sharing your health information with other individuals like your parents or guardians. This should be completed and submitted by the patient prior to their first appointment at Pohala*. They are then to be completed every 1 calendar year thereafter until the patient turns 18 years of age. It will take approximately 10 minutes to take.


The answers you provide here are private, and will be used only in regards to your healthcare. These answers are protected under HIPAA and will remain confidential.
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Email *
What is your full legal name? *
What name should we call you, if different?
What is your date of birth? *
MM
/
DD
/
YYYY
Sex Assigned at Birth? *
Gender (Please choose the option you identify with) *
Required
Pronouns? *
Required
Do you want appointment reminders and healthcare communication to go to you or your parent/guardian? *
What phone number should we use to send appointment reminders? *
Can we leave a detailed message about your healthcare on that phone number? If not is there a better number to leave this information on? Or would you prefer we do not leave detailed messages? *
Should appointment reminders be a text or call or email? You can select more than one. *
Required
At Pohala you will have a "Patient Portal", your patient portal account will include information such has lab results, messages between you and your provider, prescription information, after visit notes, etc. Please list your email so we can get you access. It is important that you set this up. *
Do you authorize your parent/guardian to also have access to your patient portal account as well? If you do they can set it up for you. *
If you selected yes, please include their email here. If you selected no, please type n/a. *
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