Sample HEADSSS Quick Screen*
This is a quick verbal screen. Whenever necessary, go into more detail. (See, also, the Body and HEADSSS long form.) Feel free to pick and choose questions to adapt to your clinic's needs.
BODY: Do you like your body? Are you too tall? Too short? Too heavy? Too light?
HOME: How are things going at home? Who lives at home? Do you get along with the other people in your house?
EDUCATION: What school do you attend? How are your grades? What grades do you think you should be getting? How many days of school have you missed?
ACTIVITIES: What do you do after school? Do you have a job? Who are your best friends?
DRUGS: Do any of your friends smoke? Drink alcohol? Use drugs? Have you ever tried...? Does anyone in your family have trouble with alcohol? Drugs?
SEX: Do you have a boyfriend/girlfriend? How long have you been going out? Are you getting along? Have you ever had sex? When you have sex, is it with men, women or both? Do you know how to protect yourself from pregnancy, STIs, and AIDS?
SUICIDE/DEPRESSION: How have your moods been? Do you ever feel down or depressed? Have you ever felt like hurting yourself or suicide? Do you know anyone who has committed suicide?
SAFETY: Are things safe for you at home? At school? In your neighborhood? Has anyone ever hurt you? Physically? Sexually?
* Adapted from Reif, CJ, Elster, AB, Adolescent Preventive Services. In Primary Care: Clinics in Office Practice, Vol 25, No 1, March 1998, WB Saunders, Philadelphia.
Minnesota Health Improvement Partnership Adolescent Health Services Action Team in partnership with the Minnesota Department of Health, Updated 2006