PHYSICAL FITNESS

How fast can your child run in a race?

Very fast Good physically fitness
Fast
Slowly Moderate physically fitness
Very slowly
Not run at all Poor physically fitness


PHYSICAL FITNESS

You answered that your child had greater than average difficulty doing physical activities.

Have you talked to anyone about your child's physical fitness?

Yes

No



PHYSICAL FITNESS

You answered that you have talked to someone about your child's physical fitness.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all



PHYSICAL FITNESS

You answered that you talked to someone about your child's physical fitness.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others



FEELINGS

During the past month, how often did your child seem sad, unhappy, worried, or upset?

None of the time Happy child
A little of the time
Some of the time Content child
Most of the time
All of the time Sad child


FEELINGS

You answered that your child has been bothered more than average by his/her feelings.

Have you talked to anyone about your child's feelings?

Yes

No

 



FEELINGS

You answered that you have talked to someone about your child's feelings.

Was what you were told helpful to you?

Extremely

Quite a lot

Moderately

A little

Not at all



FEELINGS

You answered that you have talked to someone about your child's feelings.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others



How many hours a day during the week does your child watch television?

Less than 1 hour

1-3 hours

More than 3 hours



HEALTH HABITS

How often does your child practice good health habits, such as:

All of the time Child practicing good health habits
Most of the time
Some of the time Child practicing moderate health habits
A little of the time
None of the time Child practicing poor health habits


Does your child take medications for an illness or a medical problem?

Yes

No



In the past month, did your child have an illness or injury that kept him or her in bed for all or most of the day?

Yes

No



SOCIAL ACTIVITIES

During the past 4 weeks, has your your child's physical and emotional health limited his/her social activities with family friends, neighbors or groups?

Not at all Child with no limitations in social activities
Slightly
Moderately Child with moderate limitations in social activities
Quite a bit
Extremely Child with extreme limitations in social activities


During the past month, how well did your child do in preschool or school?
Very well Good student
As well as she/he could
Could have done better Moderate student
Could have done much better
Very poor Poor student
Not in school


How is your child speaking compared to other children the same age?

Very well
Ok
Not very well
I am not sure


During the past month, how well did your child do in preschool or school?
Very well Good student
As well as she/he could
Could have done better Moderate student
Could have done much better
Very poor Poor student
Not in school


How often is your child bothered by problems with:

None
A little
Some
Often
Always
Behavior and temper
Breathing problems
Chest pains
Colds, sore throats, or fevers
Ear infections
Eating problems
Headaches
Skin problems
Sleep
Stomach pains
Tired and low energy
Trouble hearing
Trouble paying attention
Trouble seeing


In general, how much have doctors and nurses helped you and your child control these problems?

A lot

Some

A little

Not much

No help



Does your child have a single health care doctor or nurse or health care practice site that you consider the medical home for your child?

Yes

No

Not sure



Do your child's doctors or nurses spend enough time with you and your child at your child's visits?

Always

Usually

Sometimes

Seldom

Never



Do your child's doctors or nurses answer your concerns about your child?

Always

Usually

Sometimes

Seldom

Never



Are there things about your child's medical care that could be better?

No, the care is perfect

Yes, some things

Yes, a lot of things



How easy is it to get medical care for your child when you need it?
Very easy

Easy

Somewhat difficult

Very difficult

My child has not needed medical care



Has your child had?
Yes
No
Not sure
2nd MMR (Measles/Mumps/Rubella) Shot?
Tetanus Booster near the time he/she started school?
Either Chicken Pox or the Chicken Pox Vaccine


Do you have a written copy of the immunizations (shots) your child has had?
Yes

No

I am not sure



In the past year, has your child seen:

A dentist

An eye doctor

A counselor/psychologist

Another doctor



Does your child have any of the following
Mark all that apply?
Yes
No
Asthma
Another disease
Obesity (more than 15% overweight)


SOCIAL SUPPORT

During the past month, if you needed someone to listen or help about your child, was someone there for for you?

Yes, as much as I wanted Person with good social support
Yes, quite a bit
Yes, some Person with moderate social support
Yes, a little
No, not at all Person with no social support


SOCIAL SUPPORT

You answered that you had very little or no social support.

Have you talked to anyone about this problem?

Yes

No



SOCIAL SUPPORT

You answered that you talked to someone about your child's social support.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all



SOCIAL SUPPORT

You answered that your child had very little or no social support.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others



Describe here any medical errors (mistakes) that your child has experienced. Errors include such things as mixed up medicines or poor treatment that caused harms or additional problems. If possible, please tell us the cause of the error and how it might have been avoided. Your response will help us improve future care.

Are you the child's:

Mother

Stepmother

Father

Stepfather

Other



HEALTH HABITS (Home Protection)

How much have you done to protect your child, such as:
  • Have the Poison Control phone number?
  • Store drugs, cleaners, guns, matches out of reach?
  • Set hot water heater to a temperature less than 130 degrees?
  • Prevent from drowning?
  • Have a working smoke detector?
Every safe thing that I know
Almost every safe thing
Some safe things
A few safe things
Not many safe things


HEALTH HABITS (Safety)

How much have you done to keep your child safe outside of the home such as:

  • Using seat belts?
  • Making sure the car is inspected and safe?
  • Not leaving your child alone in public places?
  • Not allowing the child to be with careless or dangerous persons?
Every safe thing that I know
Almost every safe thing
Some safe things
A few safe things
Not many safe things


HEALTH HABITS (Your Health Habits)

Your health habits impact your child. How are you doing with such health habits as:

  • Your use of cigarette and tobacco products?
  • Your temper?
  • Your eating and exercise habits?
  • Your use of regular medical care for yourself?
  • Your use of alcohol?

Perfectly
Very well
Pretty good
Only fair
Poor


RELATIONSHIPS

During the past 4 weeks, how often have problems in your household led to: Insulting or swearing? Threatening? Yelling? Hitting or pushing?

None of the time Family with good family relations
A little of the time
Some of the time Family with moderate family relations
Most of the time
All of the time Family with poor family relations


Do you have enough money to buy the essential things you need such as food, clothing, or housing?

Yes, always

Yes, sometimes

No



Do you have concerns about:

How to keep my child safe
What is normal for my child
Health, eating, and habits
How to manage pain
How to manage behavior problems
How to help learning
How to manage school or day care problems
When money is hard to find, how can I help my child


You indicated earlier that your child has asthma or a breathing problem.

How would you rate the information your doctor or a nurse gave you about:
Excellent Very Good Good Fair Poor I do not remember receiving any information
How to adjust medicines for your child's shortness of breath?
How to use inhaled medicines?
How to make asthma treatment fit in to your child's everyday life?


Does your child use an inhaled steroid?

Yes

No

Not sure



THANK YOU FOR COMPLETING THIS QUESTIONAIRE.... PLEASE MAP THE APPROPRIATE LOCATION FOR THE RESPONSES ON THE ACTION AND LETTER FORM. THANKS

You will be asked questions about your child in three sections:

Picture of a child
About Him or Her

Picture of a doctor examining a child
About Health and Medical Care

Picture of a child and a house
About Home



Questions About Your Child:

Picture of a child


Now Some Questions About Your Child's Medical Care:
Picture of a doctor examining a child


Now About Home and Your Care of the Child:
Picture of a child and a house


Finally, please enter your zip code. If you are willing, please also indicate your employer and and health care provider information along with your usual hospital.

Entering your zip code and other information is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.

ZIP:

Employer
Health Care Provider
Hospital


Finally, please enter your zip code. If you are willing, please also indicate your employer and and health care provider information along with your usual hospital.

Entering your zip code and other information is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.

ZIP:

Employer
Health Care Provider
Hospital


Describe here any medical errors (mistakes) that you or your family have experienced. Errors include such things as mixed up medications or poor treatment that result in harm or additional problems. If possible, be sure to tell us the cause of the error and how it might have been avoided.Your response will help us to improve future care delivery.



Finally, please enter your zip code.

Entering your zip code is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.