These self-assessment tools are designed for young male patients – one for ages 10-13 and the other for ages 14-18 – to help provide a picture of overall health and wellbeing. This assessment can be shared with a healthcare provider, who can answer any questions you might have about the questions covered.
Taking care of you is your healthcare team’s most important job! ASHA developed these tools to help your provider give you the very best care. We suggest you fill out the appropriate form for your age, print it, and feel free to bring it with you to your discuss with your healthcare provider:
The information on this sheet will let you know what to expect when you’re with the healthcare provider. There are also some questions for you to answer. These are meant to help you think about how you’re feeling physically and mentally, and to remind you about things you may want to talk about. Anything discussed during your visit is private and isn’t shared unless your provider is worried that you or someone else may need help or may be at risk of harm.
If you don’t have an appointment with a healthcare provider but feel concerned about something, reach out to someone you trust, your parents, a teacher or an adult who can help.
Remember, your health is your power!
*If you are unable to complete the form in your browser, download it and open in Adobe Reader to fill it out.
This self assessment tool was developed by the American Sexual Health Association, School-Based Health Alliance, Healthy Teen Network, and Partnership for Male Youth, through an independent educational grant from Merck and Company.