|How well do I manage my own health care?||Please circle (yes/no)|
|I know my height, weight, birth date, and social security number.||Yes||No|
|I know the name of my condition and can explain my special health care needs.||Yes||No|
|I know who to call in the case of an emergency.||Yes||No|
|I ask questions during my medical appointments.||Yes||No|
|I respond to questions from my health care providers.||Yes||No|
|I know what kind of medical insurance I have.||Yes||No|
|I know the names of my medications and what they do||Yes||No|
|I know how to get my prescriptions refilled.||Yes||No|
|I know where to find my medical records.||Yes||No|
|I know how the use of tobacco, alcohol, and drugs will affect my health and my ability to make decisions.||Yes||No|
|I know how to get birth control and protection from sexually transmitted diseases if I need it.||Yes||No|
|I know how to schedule a medical appointment.||Yes||No|
|I keep a schedule of my medical appointments on a calendar.||Yes||No|
|I can get myself to my medical appointments.||Yes||No|
To download a printer friendly-version of this checklist click on the file below.
Adapted from the Children's Hospital Boston, Massachusetts Initiative for Youth with Disabilities Project, a Healthy and Ready to Work project of the Massachusetts Department of Public Health. Available at Boston LEAH (Leadership Education in Adolescent Health) website.
This information is provided by the Division for Children & Youth with Special Health Needs within the Department of Public Health .