Sample HEADSSS Questions (Long Form)*

Colorful graphic of 4 adolescents.

Here are some ideas on how to question teens in detail. Feel free to pick and choose questions based on your clinic's needs.

Subject

Long Form

Short Form

Body

How much time do you think about ways to be thin? Do you ever use laxatives, diet pills, starve yourself or throw-up on purpose after eating? How many times have you gone on a diet this year? How do you diet? Have you ever eaten alone or in secret? How many times a week do you exercise? What do you do for exercise? Have you ever been told you have an eating disorder?

Do you get some exercise at least 3 times a week? Do you feel you are the right weight for your height? Do you ever throw-up or use laxatives after eating?

Home

Where do you live? Who do you live with? Do you share a bedroom? With whom? How do you get along with the people you live with? How much time do you spend at home? What do you and your family argue about? Can you go to your parents/guardian with problems? Have you ever run away from home?

How are things at home? Who lives at home? How do you get along with the other people in your house?

Education

What school do you go to? What grade are you in? What kind of grades do you get? Have they changed? What are your best/worst classes? Why? Do you need extra help in school? Do you work after school or on weekends? Have you ever failed any classes or a grade? Do you ever cut classes?

How are things at school? What classes do you like best? Least? Grades?

Activities

What do you do for fun? What activities are you involved in during and after school? Are you active in sports? Do you exercise? Who do you do fun things with? Do you have a best friend? Who do you hang out with? Who are your friends? Who do you go to with problems? What do you do on weekends? Evenings?

How many good friends do you have? What do you do together? What do your parents/guardian think of your friends?

Drugs

Do you drink coffee, tea or caffeinated colas? Do you smoke cigarettes or chew? Have you ever smoked one? Have you ever tasted alcohol? When? What kind? How often? Do any of your friends smoke, drink or use drugs? What drugs have you tried? Have you ever injected drugs or steroids? When? How often do you use them? How did you pay for the drugs?

Do any of your friends smoke? Drink alcohol? Do you? Have you tried other drugs?

Sexual Activity/Sexual Identity

Have you ever had sex with men? Women? Both? Do you ever wonder if you are gay, lesbian, bisexual or transgendered? Have you ever had sex unwillingly? How many sexual partners have you had? How old were you when you first had sex? Have you ever been pregnant? Have you ever had an infection as a result of sex? Do you use condoms or another form of contraception for prevention against sexually transmitted infections (STI) and/or pregnancy? Have you ever traded sex for money, drugs, clothes or a place to stay? Have you ever had an STI? Have you ever been tested for HIV? Do you think it would be a good idea to be tested?

Are you attracted to boys? Girls? Do you have a boyfriend or girlfriend? How long? Do you get along well? Do you have sex? Does it go OK? Do you know how to say "no"? Do you know how to protect yourself from STIs and pregnancy?

Suicide/Depression

How do you feel today on a scale of zero to ten, with zero as very sad and ten as very happy? Have you ever felt less than five? What made you feel that way? Did you ever: Think about hurting yourself? Think that life wasn't worth living? Hope that when you went to sleep you wouldn't wake up again? Do you know anyone who has committed suicide?

Do you ever feel really depressed? How long does it last? Have you ever thought of hurting yourself or suicide?

Safety

Are you afraid of violence in your school? In your neighborhood? At home? Do you carry a weapon to school? What kind and how often? Do your friends carry weapons? What kind? Do you have a personal history of fighting? Have you used weapons? Are there guns in your home? Do you have access to them? Have you been a victim of a violent crime? When? Where? Who was involved? What happened? Do you have a history of physical abuse? Have you been the victim of date rape or rape? Have you been arrested? Have you run away from home? Been homeless? Been involved with cults? Are you a member of a gang?

Do you ever feel unsafe? When? At school? At home? In your neighborhood? Have you ever been hurt by someone?

* Adapted from Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5(7):75-90. Copyright 1988 Medical Economics Publishing Inc., Montvale, N.J. Reprinted with permission.

 

Minnesota Health Improvement Partnership Adolescent Health Services Action Team in partnership with the Minnesota Department of Health, Updated 2006