Please provide the last 4 digits of your phone number ________
FEMALE ADOLESCENT PATIENT
The following question refers to care in the Emergency Department (ED).
The patient is:
Female
≥ 14 years of age
With potential genitourinary complaints (i.e., lower abdominal pain, vaginal/pelvic complaints or urinary complaints)
Please answer N/A (not applicable) if you have never taken care of an adolescent patient before in the ED.
When treating such a female adolescent patient in the ED, how MOTIVATED would you be to…
Not at All Fairly Moderately Extremely N/A
1. Ask a parent/guardian to step out of the room in order to obtain a private health history?
q q q q q
2. Obtain a sexual history? q q q q q
3. Discuss condoms in the ED?
q q q q q
4. Offer condoms in the ED? q q q q q
When treating such a female adolescent patient in the ED, how CONFIDENT IN YOUR SKILLS would you be to…
Not at All Fairly Moderately Extremely N/A
5. Ask a parent/guardian to step out of the room in order to obtain a private health history?
q q q q q
6. Obtain a sexual history? q q q q q
7. Discuss condoms in the ED?
q q q q q
8. Offer condoms in the ED? q q q q q
MALE ADOLESCENT PATIENT
The following question refers to care in the Emergency Department (ED).
The patient is:
Male
≥ 14 years of age
With potential genitourinary complaints (i.e., penile or urinary complaints)
Please answer N/A (not applicable) if you have never taken care of an adolescent patient before in the ED.
When treating this male adolescent patient in the ED, how MOTIVATED would you be to…
Not at All Fairly Moderately Extremely N/A
9. Ask a parent/guardian to step out of the room in order to obtain a private health history?
q q q q q
10. Obtain a sexual history? q q q q q
11. Discuss condoms in the ED?
q q q q q
12. Offer condoms in the ED?
q q q q q
When treating such a male adolescent patient in the ED, how CONFIDENT IN YOUR SKILLS would you be to…
Not at All Fairly Moderately Extremely N/A
13. Ask a parent/guardian to step out of the room in order to obtain a private health history?
q q q q q
14. Obtain a sexual history? q q q q q
15. Discuss condoms in the ED?
q q q q q
16. Offer condoms in the ED?
q q q q q
Please indicate your level of agreement or disagreement with the following statements.
Strongly Disagre
e
Disagre
e Agree Strongly Agree
17. I lack sufficient training in obtaining sexual histories from adolescents
q q q q
18. I am concerned that there is not enough time in an ED visit to appropriately discuss sexual health issues
q q q q
Please indicate your level of agreement or disagreement with the following statements.
Strongly Disagre
e
Disagre
e Agree Strongly Agree
19. Providing condoms promotes promiscuity among adolescents
q q q q
20. I am more comfortable discussing sex with older adolescents rather than younger ones
q q q q
21. Because of my
religious /cultural beliefs I am uncomfortable discussing sex with adolescent patients.
22. Because of my
religious/cultural beliefs, I am uncomfortable offering
condoms to adolescent patients.
q q q q
23. I lack sufficient training in obtaining sexual histories from adolescents
q q q q
24. I am concerned that there is not enough time in an ED visit to appropriately discuss sexual health issues
q q q q