2020 SCDAA-MI Transition Readiness Pre-Assessment

Please fill out this form to help us see what you already know about your health and how to use health care and the areas that you want to learn more about. If you need help completing this form, please ask your parent/caregiver.

Question Title

* 1. Your information:

Question Title

* 2. Transition and Self-Care Importance and Confidence
On a scale of 0 to 10, please select the number that best describes how you feel now.

  0 (not) 1 2 3 4 5 6 7 8 9 10 (very) Not applicable (#3 only)
1. How important is it to you to manage your own health care?
2. How confident do you feel about your ability to manage your own health care?
3. How confident do you feel about preparing for/changing to an adult doctor before the age of 22? 

Question Title

* 3. My Health Please check the box that applies to you right now.
Knowledge

  No, I do not know/understand

No, but I am learning Yes, I somewhat know/ understand Yes
I know what type of sickle cell disease I have.
I know my medical needs and can explain them to someone.
I know what a hematologist is and why I go to one.
I know what to do in case of a medical emergency.
I understand what causes (triggers) my pain episode.
I understand how drugs, alcohol and tobacco affect sickle cell disease.
I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.).
I know how to get blood work and x-rays.
I know what my medications are for.
I know the names and doses of my medications.
I know what hydroxyurea is and how it prevents sickling of my red blood cells.
I know how to prevent a pain episode and what to do if I have pain.
I understand my insurance plan
I understand how health care privacy changes at age 18, when I am legally an adult.

Question Title

* 4. My Health Please check the box that applies to you right now.
Skills

  No, I do not do this

No, but I am learning to do this Yes, I have started to do this Yes, I always do this when I need to
I talk to my friends about sickle cell disease.
I make my own doctors’ appointments.
I can get medical care when the doctor’s office is closed.
I fill out my own medical history form
I keep track of my own medical information.
I keep track of my doctors’ and other appointments.
I make a list of questions before my visit with my doctors.
I answer questions on my own during medical visits.
I arrange my own transportation to medical appointments.
I remember to take my medications without my parent reminding me.
I fill prescriptions before I run out of medications.
I carry my own insurance card.
0 of 4 answered
 

T