Adapted from "Six Core Elements of Health Transition 2.0," Sample Transition Readiness Assessment for Youth by Got
Transition/Center for Health Care Transition Improvement, 2014, The National Alliance to Advance Adolescent Health.
Retrieved from https://www.GotTransition.org. Copyright 2014 by Got Transition.
How important is it to you to prepare for/transfer to an adult clinician before age 18?
0 (NOT Important)
1
2
3
4
5
6
7
8
9
10 (Very Important)
How confident do you feel about your ability to prepare for/transfer to an adult clinician before age 18?
0 (NOT Confident)
1
2
3
4
5
6
7
8
9
10 (Very Confident)
Scan here to learn about our Transition Policy!
Things I need to know
or do
Will someone
else have to do
this for me?
I will finish
by (date)
Scan this Code
with a Smart
Phone to
Learn More!
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Adapted from "Six Core Elements of Health Transition 2.0," Sample Transition Readiness Assessment for Youth by Got Transition/Center for
Health Care Transition Improvement, 2014, The National Alliance to Advance Adolescent Health. Retrieved from
https://www.GotTransition.org. Copyright 2014 by Got Transition.
Independent Living
Things I need to
know or do
Will someone else
have to do this for
me?
I will
finish by
(date)
Scan this
Code with a
Smart Phone
to Learn
More!
10. I know or I can find my doctor’s phone number
.
YES, I know this NO, I need to learn
YES NO
11. I make my own doctor appointments.
YES, I know this NO, I need to learn
YES NO
12. Before a visit, I think about questions to ask.
YES, I know this NO, I need to learn
YES NO
13. I have a way to get to my doctor’s office.
YES, I know this NO, I need to learn
YES NO
14. I know to show up 15 minutes before the visit to check in.
YES, I know this NO, I need to learn
YES NO
15. I know where to go to get medical care when the doctor’s
office
is closed.
YES, I know this NO, I need to learn
YES NO
16. I have a file at home for my medical information
YES, I know this NO, I need to learn
YES NO
17. I have a copy of my current plan of care.
YES, I know this NO, I need to learn
YES NO
18. I know how to fill out medical forms.
YES, I know this NO, I need to learn
YES NO
19. I know to get referrals to other providers.
YES, I know this NO, I need to learn
YES NO
20. I know where my pharmacy is and how to refill my medicines.
YES, I know this NO, I need to learn
YES NO
21. I know where to get blood work or x-rays if my doctor orders
them.
YES, I know this NO, I need to learn
YES NO
22. I have a plan so I can keep my health insurance after 18 or
older.
YES, I know this NO, I need to learn
YES NO
23. My family and I have discussed my ability to make my own
healthcare decisions at age 18.
YES, I know this NO, I need to learn
YES NO
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