2020 SCDAA-MI Transition Readiness Pre-Assessment (revised 1/24/2020)

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:

Name

Date

Age

Gender

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

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 what type of sickle cell disease I have. No, I do not know/understand	I know what type of sickle cell disease I have. No, but I am learning	I know what type of sickle cell disease I have. Yes, I somewhat know/ understand	I know what type of sickle cell disease I have. Yes
I know my medical needs and can explain them to someone.	I know my medical needs and can explain them to someone. No, I do not know/understand	I know my medical needs and can explain them to someone. No, but I am learning	I know my medical needs and can explain them to someone. Yes, I somewhat know/ understand	I know my medical needs and can explain them to someone. Yes
I know what a hematologist is and why I go to one.	I know what a hematologist is and why I go to one. No, I do not know/understand	I know what a hematologist is and why I go to one. No, but I am learning	I know what a hematologist is and why I go to one. Yes, I somewhat know/ understand	I know what a hematologist is and why I go to one. Yes
I know what to do in case of a medical emergency.	I know what to do in case of a medical emergency. No, I do not know/understand	I know what to do in case of a medical emergency. No, but I am learning	I know what to do in case of a medical emergency. Yes, I somewhat know/ understand	I know what to do in case of a medical emergency. Yes
I understand what causes (triggers) my pain episode.	I understand what causes (triggers) my pain episode. No, I do not know/understand	I understand what causes (triggers) my pain episode. No, but I am learning	I understand what causes (triggers) my pain episode. Yes, I somewhat know/ understand	I understand what causes (triggers) my pain episode. Yes
I understand how drugs, alcohol and tobacco affect sickle cell disease.	I understand how drugs, alcohol and tobacco affect sickle cell disease. No, I do not know/understand	I understand how drugs, alcohol and tobacco affect sickle cell disease. No, but I am learning	I understand how drugs, alcohol and tobacco affect sickle cell disease. Yes, I somewhat know/ understand	I understand how drugs, alcohol and tobacco affect sickle cell disease. Yes
I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.).	I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.). No, I do not know/understand	I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.). No, but I am learning	I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.). Yes, I somewhat know/ understand	I know about necessary screening exams (echo annually, kidney function annually, retinal exams, etc.). Yes
I know how to get blood work and x-rays.	I know how to get blood work and x-rays. No, I do not know/understand	I know how to get blood work and x-rays. No, but I am learning	I know how to get blood work and x-rays. Yes, I somewhat know/ understand	I know how to get blood work and x-rays. Yes
I know what my medications are for.	I know what my medications are for. No, I do not know/understand	I know what my medications are for. No, but I am learning	I know what my medications are for. Yes, I somewhat know/ understand	I know what my medications are for. Yes
I know the names and doses of my medications.	I know the names and doses of my medications. No, I do not know/understand	I know the names and doses of my medications. No, but I am learning	I know the names and doses of my medications. Yes, I somewhat know/ understand	I know the names and doses of my medications. Yes
I know what hydroxyurea is and how it prevents sickling of my red blood cells.	I know what hydroxyurea is and how it prevents sickling of my red blood cells. No, I do not know/understand	I know what hydroxyurea is and how it prevents sickling of my red blood cells. No, but I am learning	I know what hydroxyurea is and how it prevents sickling of my red blood cells. Yes, I somewhat know/ understand	I know what hydroxyurea is and how it prevents sickling of my red blood cells. Yes
I know how to prevent a pain episode and what to do if I have pain.	I know how to prevent a pain episode and what to do if I have pain. No, I do not know/understand	I know how to prevent a pain episode and what to do if I have pain. No, but I am learning	I know how to prevent a pain episode and what to do if I have pain. Yes, I somewhat know/ understand	I know how to prevent a pain episode and what to do if I have pain. Yes
I understand my insurance plan	I understand my insurance plan No, I do not know/understand	I understand my insurance plan No, but I am learning	I understand my insurance plan Yes, I somewhat know/ understand	I understand my insurance plan Yes
I understand how health care privacy changes at age 18, when I am legally an adult.	I understand how health care privacy changes at age 18, when I am legally an adult. No, I do not know/understand	I understand how health care privacy changes at age 18, when I am legally an adult. No, but I am learning	I understand how health care privacy changes at age 18, when I am legally an adult. Yes, I somewhat know/ understand	I understand how health care privacy changes at age 18, when I am legally an adult. Yes

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 talk to my friends about sickle cell disease. No, I do not do this	I talk to my friends about sickle cell disease. No, but I am learning to do this	I talk to my friends about sickle cell disease. Yes, I have started to do this	I talk to my friends about sickle cell disease. Yes, I always do this when I need to
I make my own doctors’ appointments.	I make my own doctors’ appointments. No, I do not do this	I make my own doctors’ appointments. No, but I am learning to do this	I make my own doctors’ appointments. Yes, I have started to do this	I make my own doctors’ appointments. Yes, I always do this when I need to
I can get medical care when the doctor’s office is closed.	I can get medical care when the doctor’s office is closed. No, I do not do this	I can get medical care when the doctor’s office is closed. No, but I am learning to do this	I can get medical care when the doctor’s office is closed. Yes, I have started to do this	I can get medical care when the doctor’s office is closed. Yes, I always do this when I need to
I fill out my own medical history form	I fill out my own medical history form No, I do not do this	I fill out my own medical history form No, but I am learning to do this	I fill out my own medical history form Yes, I have started to do this	I fill out my own medical history form Yes, I always do this when I need to
I keep track of my own medical information.	I keep track of my own medical information. No, I do not do this	I keep track of my own medical information. No, but I am learning to do this	I keep track of my own medical information. Yes, I have started to do this	I keep track of my own medical information. Yes, I always do this when I need to
I keep track of my doctors’ and other appointments.	I keep track of my doctors’ and other appointments. No, I do not do this	I keep track of my doctors’ and other appointments. No, but I am learning to do this	I keep track of my doctors’ and other appointments. Yes, I have started to do this	I keep track of my doctors’ and other appointments. Yes, I always do this when I need to
I make a list of questions before my visit with my doctors.	I make a list of questions before my visit with my doctors. No, I do not do this	I make a list of questions before my visit with my doctors. No, but I am learning to do this	I make a list of questions before my visit with my doctors. Yes, I have started to do this	I make a list of questions before my visit with my doctors. Yes, I always do this when I need to
I answer questions on my own during medical visits.	I answer questions on my own during medical visits. No, I do not do this	I answer questions on my own during medical visits. No, but I am learning to do this	I answer questions on my own during medical visits. Yes, I have started to do this	I answer questions on my own during medical visits. Yes, I always do this when I need to
I arrange my own transportation to medical appointments.	I arrange my own transportation to medical appointments. No, I do not do this	I arrange my own transportation to medical appointments. No, but I am learning to do this	I arrange my own transportation to medical appointments. Yes, I have started to do this	I arrange my own transportation to medical appointments. Yes, I always do this when I need to
I remember to take my medications without my parent reminding me.	I remember to take my medications without my parent reminding me. No, I do not do this	I remember to take my medications without my parent reminding me. No, but I am learning to do this	I remember to take my medications without my parent reminding me. Yes, I have started to do this	I remember to take my medications without my parent reminding me. Yes, I always do this when I need to
I fill prescriptions before I run out of medications.	I fill prescriptions before I run out of medications. No, I do not do this	I fill prescriptions before I run out of medications. No, but I am learning to do this	I fill prescriptions before I run out of medications. Yes, I have started to do this	I fill prescriptions before I run out of medications. Yes, I always do this when I need to
I carry my own insurance card.	I carry my own insurance card. No, I do not do this	I carry my own insurance card. No, but I am learning to do this	I carry my own insurance card. Yes, I have started to do this	I carry my own insurance card. Yes, I always do this when I need to