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CHQ- PF50CHI LD HEALTH QUESTI ONNAI RE 

 YOUR CHI LD' S GLOBAL HEALTH - SECTI ON 1

Q1. 1 I n gener al , woul d you say your chi l d' s heal t h i s:{Q1q1}: ### ( 1) Excel l ent( 2) Very Good( 3) Good ( 4) Fai r( 5) Poor 

 YOUR CHI LD' S PHYSI CAL ACTI VI TI ES - SECTI ON 2

Q2. 1 Dur i ng the past f our weeks, has your chi l d been l i mi t ed i n  any of t he f ol l owi ng act i vi t i es due t o heal t h pr obl ems?

( 1) Yes, l i mi t ed a l ot .( 2) Yes, l i mi t ed some(3) Yes , l i mi ted a l i t t l e.  ( 4) No, not l i mi t ed.

{Q2q1a}: ### Doi ng t hi ngs t hat t akes a l ot ofenergy such as pl ayi ng soccer or r unni ng?

{Q2q1b}: ### Doi ng t hi ngs t hat t akes some energy such as r i di ng a bi ke or skat i ng?

{Q2q1c}: ### Abi l i t y ( physi cal l y) t o get around t he nei ghbor hood,  pl aygr ound, or school ? {Q2q1d}: ### Wal ki ng one bl ock or cl i mbi ng one f l i ght of st ai r s?{Q2q1e}: ### Bendi ng, l i f t i ng, or st oopi ng? 

{Q2q1f }: ### Taki ng care of hi m/ her sel f , t hat i s,eat i ng, dr essi ng, bat hi ng, or goi ng t o the t oi l et ?

 YOUR CHI LD' S EVERYDAY ACTI VI TI ES - SECTI ON 3

Q3. 1 Dur i ng t he past f our weeks, has your chi l d' s school  wor k  or act i vi t i es wi t h f r i ends been l i mi t ed i n any of t hef ol l owi ng ways days t o EMOTI ONAL di f f i cul t i es or pr obl emswi t h hi s/ her BEHAVI OR?

( 1) Yes, Li mi t ed a l ot .  

( 2) Yes, l i mi t ed some.(3) Yes , l i mi ted a l i t t l e.  ( 4) No, not l i mi t ed.  

{Q3q1a}: ### l i mi t ed i n t he KI ND of school work oract i vi t i es wi t h f r i ends he/ she coul d do

{Q3q1b}: ### l i mi t ed i n t he AMOUNT of t i me he/ she coul d spend on school - wor k or acti vi t i es wi t h f r i ends 

{Q3q1c}: ### l i mi t ed i n PERFORMI NG school wor k oract i vi t i es wi t h f r i ends ( i t t ook ext ra ef f ort )

Q3. 2 Dur i ng the past f our weeks, has your chi l d' s school work

or act i vi t i es wi t h f r i ends been l i mi t ed i n any of t hef ol l owi ng ways due to pr obl ems wi t h hi s/ her PHYSI CAL heal t h?( 1) Yes, l i mi t ed a l ot  ( 2) Yes, l i mi t ed some(3) Yes , l i mi ted a l i t t l e.  ( 4) No, not l i mi t ed.

{Q3q2a}: ### l i mi t ed i n t he KI ND of school work oract i vi t i es wi t h f r i ends he/ she coul d do

{Q3q2b}: ### l i mi t ed i n t he AMOUNT of t i me he/ she coul d spend on school wor k or acti vi t i es wi t h f r i ends

PAI N - SECTI ON 4

Q4. 1 Dur i ng t he past f our weeks, how much bodi l y pai n or  di scomf or t   has your chi l d had? {Q4q1}: ###

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( 1) None ( 2) Ver y mi l d ( 3) Mi l d( 4) Moderat e ( 5) Sever e( 6) Ver y sever e 

Q4. 2 Dur i ng the past f our weeks, how of t en has your chi l d hadbodi l y pai n or di scomf or t ? {Q4q2}: ###

( 1) None of t he t i me( 2) Once of t wi ce ( 3) A f ew t i mes ( 4) Fai r l y of t en

( 5) Ver y Of t en ( 6) Ever y/ al most every day

BEHAVI OR - SECTI ON 5

Q5. 1 How of t en dur i ng t he past f our weeks di d each of t hef ol l owi ng st at ement s descr i be your chi l d?

( 1) Ver y of t en ( 2) Fai r l y of t en ( 3) Somet i mes( 4) Al most never  ( 5) Never

{Q5q1a}: ### ar gued a l ot{Q5q1b}: ### had di f f i cul t y concent r at i ng or payi ng at t ent i on{Q5q1c}: ### l i ed or cheat ed {Q5q1d}: ### st ol e t hi ngs i nsi de or out si de t he home{Q5q1e}: ### had t ant r ums or a hot t emper  

Q5. 2 Compar ed t o ot her chi l dr en your chi l d' s age, i n gener al  woul d  you say hi s/ her behavi or i s: {Q5q2}: ###

( 1) Excel l ent( 2) Very good( 3) Good

( 4) Fai r( 5) Poor 

WELL- BEI NG - SECTI ON 6

Q6. 1 Dur i ng t he past f our weeks, how much of t he t i me do yout hi nk your chi l d:

( 1) Al l of t he t i me ( 2) Most of t he t i me( 3) Some of t he t i me ( 4) A l i t t l e of t he t i me ( 5) None of t he t i me

{Q6q1a}: ### f el t l i ke cryi ng?{Q6q1b}: ### f el t l onel y? {Q6q1c}: ### act ed nervous? 

{Q6q1d}: ### act ed bot hered or upset ?{Q6q1e}: ### act ed cheerf ul ? 

SELF- ESTEEM - SECTI ON 7

Q7. 1 Dur i ng t he past f our weeks, how sat i sf i ed do you t hi nk your   chi l d has f el t about :

( 1) Very sat i sf i ed ( 2) Somewhat sat i sf i ed ( 3) Nei t her sat i sf i ed nor di ssat i sf i ed( 4) Somewhat di ssat i sf i ed ( 5) Ver y di ssat i sf i ed

{Q7q1a}: ### hi s/ her school abi l i t y?{Q7q1b}: ### hi s/ her athl et i c abi l i t y?{Q7q1c}: ### hi s/ her f r i endshi ps? 

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{Q7q1d}: ### hi s/ her l ooks/ appearance?{Q7q1e}: ### hi s/ her f ami l y rel at i onshi ps? {Q7q1f }: ### hi s/ her l i f e over al l ? 

 YOUR CHI LD' S HEALTH - SECTI ON 8

Q8. 1 How t r ue or f al se i s each of t hese st at ement s f oryour chi l d? (1) Def i ni t el y t r ue( 2) Most l y t r ue ( 3) Don' t know( 4) Most l y f al se ( 5) Def i ni t el y f al se 

{Q8q1a}: ### My chi l d seems t o be l ess heal t hy than other chi l drenI know.

{Q8q1b}: ### My chi l d has never been ser i ousl y i l l .  {Q8q1c}: ### When t her e i s somet hi ng goi ng around my chi l d usual l y 

cat ches i t .{Q8q1d}: ### I expect my chi l d wi l l have a very heal t hy l i f e.  

{Q8q1e}: ### I wor r y mor e about my chi l d' s heal t h t hanother peopl e wor r y about t hei r chi l dr en' s heal t h.

Q8. 2 Compar ed t o one year ago, how woul d you rate your chi l d' sheal t h now: {Q8q2}: ###

( 1) Much bet t er now t han 1 year ago.( 2) Somewhat bet t er now t han 1 year ago ( 3) About t he same now as 1 year ago( 4) Somewhat wor se now t han 1 year ago( 5) Much wor se now t han 1 year ago

 YOU AND YOUR CHI LD - SECTI ON 9

Q9. 1 Dur i ng t he past f our weeks, how MUCH emot i onal wor r y orconcern di d each of t he f ol l owi ng cause YOU?

( 1) None at al l  ( 2) A l i t t l e bi t( 3) Some ( 4) Qui t e a bi t  ( 5) A l ot

{Q9q1a}: ### Your chi l d' s physi cal heal t h.{Q9q1b}: ### Your chi l d' s emot i onal wel l - bei ng or behavi or .  {Q9q1c}: ### Your chi l d' s at t ent i on or l ear ni ng abi l i t i es.  

Q9. 2 Dur i ng t he l ast f our weeks, were you LI MI TED i n the amount of t i me YOU had f or own needs becauseof : ( 1) Yes, l i mi t ed a l ot( 2) Yes, l i mi t ed some ( 3) Yes, l i mi t ed a l i t t l e( 4) No. not l i mi t ed 

{Q9q2a}: ### Your chi l d' s physi cal heal t h?{Q9q2b}: ### Your chi l d' s emot i onal wel l - bei ng or behavi or? {Q9q2c}: ### Your chi l d' s at t ent i on or l ear ni ng abi l i t i es?

Q9. 3 Dur i ng t he past f our weeks, how of t en has your chi l d' sheal t h or behavi or :

( 1) Ver y of t en( 2) Fai r l y of t en( 3) Somet i mes( 4) Al most never( 5) Never  

{Q9q3a}: ### l i mi t ed t he t ypes of act i vi t i es you  coul d do as a f ami l y?

{Q9q3b}: ### i nt err upt ed var i ous everyday f ami l y act i vi t i es( eat i ng meal s, watchi ng TV) ? 

{Q9q3c}: ### l i mi t ed your abi l i t y as a f ami l y t o "pi ck up and go" on a moment ' s not i ce?

{Q9q3d}: ### caused t ensi on or conf l i ct i n your home? 

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{Q9q3e}: ### been a source of di sagr eements orargument s i n your f ami l y?

{Q9q3f }: ### caused you to cancel or change pl ans ( per sonal or work) at t he l ast mi nut e?

Q9. 4 Somet i mes f ami l i es may have di f f i cul t y get t i ng al ong wi t hone another . They do not al ways agr ee and they may get angry.I n gener al , how woul d you r at e your f ami l y' s abi l i t y to getal ong

wi t h one another?{Q9q4}: ### 

( 1) Excel l ent

( 2) Very good( 3) Good( 4) Fai r  ( 5) Poor 

FACTS ABOUT YOUR CHI LD - SECTI ON 10

Q10. 1 I s your chi l d: ( 1) Mal e ( 2) Femal e {Q10q1}: ###

Q10. 2 Was t hi s your f i r st chi l d ( nat ur al oradopt ed)? {Q10q2}: ### ( 1) Yes ( 2) No

Q10. 3 What i s your chi l d dat e of bi r t h? {Q10q3}:

Q10. 4 What i s t he hi ghest gr ade of school your chi l d hascompl et ed? ( ci r cl e onl y one number ) {Q10q4}: ###

( 1) Preschool ( 9) 6t h Gr ade ( 2) Ki nder gart en ( 10) 7t h Gr ade ( 3) 1st Gr ade ( 11) 8th Gr ade( 4) 2nd Gr ade ( 12) 9th Gr ade( 5) 3rd Gr ade ( 13) 10t h Gr ade( 6) 4th Gr ade ( 14) 11t h Gr ade( 7) 5th Gr ade ( 15) 12t h Gr ade

(8) Ungr aded ( 16)   I f Ungr aded, How many years at t ended?

Q10. 5 Have you ever been t ol d by a t eacher , school of f i ci al ,doct or , nur se, or ot her heal t h pr of essi onal t hat our chi l d hasany of t he f ol l owi ng condi t i ons?

( 1) Yes ( 2) No

{Q10q5a}: ### Anxi et y pr obl ems{Q10q5b}: ### Ast hma{Q10q5c}: ### At t ent i onal probl ems {Q10q5d}: ### Behavi or al probl ems{Q10q5e}: ### Chr oni c al l ergi es or si nus t r oubl e {Q10q5f }: ### Chroni c ort hopaedi c, bone, or j oi nt probl ems {Q10q5g}: ### Chr oni c r espi r atory, l ung, or br eat hi ng pr obl ems

( not ast hma) {Q10q5h}: ### Chroni c r heumat i c di sease

{Q10q5i }: ### Depressi on {Q10q5j }: ### Devel opment al del ay or ment al r etardat i on {Q10q5k}: ### Di abet es{Q10q5l }: ### Epi l epsy ( sei zure di sor der)  {Q10q5m}: ### Hear i ng i mpai r ment or deaf ness{Q10q5n}: ### Lear ni ng pr obl ems {Q10q5o}: ### Sl eep di st urbance {Q10q5p}: ### Speech pr obl ems{Q10q5q}: ### Vi si on pr obl ems 

{Q10q5r}: ### Does your chi l d have any ot herchr oni c medi cal condi t i on t hat i s af f ect i ng what   t hey do or how t hey f eel ? ( Pl ease i ndi cat e

bel ow)

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FACTS ABOUT YOU - SECTI ON 11

Q11. 1 Ar e you: ( 1) Mal e ( 2) Femal e {Q11q1}: ###

Q11. 2 What i s your date of bi r t h? {Q11q2}:

Q11. 3 Whi ch of t he f ol l owi nt best descr i bes your cur r ent workst at us? (check al l t hat appl y){Q11q3a}: ### {Q11q3b}: ### {Q11q3c}: ### {Q11q3d}: ### {Q11q3e}: ### 

( 1) Not worki ng due to my chi l d' s heal t h ( 2) Not worki ng f or "ot her " r easons( 3) Looki ng f or work out si de the home 

( 4) Wor ki ng f ul l or par t t i me ( ei t her out si de t he home 

or   at a home- based busi ness)( 5) Ful l t i me homemaker  

Q11. 4 Whi ch or t he f ol l owi ng best descr i bes your r el at i onshi p t o  your chi l d?{Q11q4}: ### 

( 1) Bi ol ogi cal par ent  ( 2) St ep par ent ( 3)Fost er par ent ( 4)Adopt i ve par ent ( 5)Guar di an( 6) Ot her ( pl ease expl ai n on t he l i ne bel ow)  {Q11q4ot h}:

Q11. 5 What i s t he hi ghest grade of school you have compl eted?{Q11q5}: ### 

( 1) Some hi gh school or l ess ( 2) Hi gh school di pl oma/ GED( 3) Vocat i onal school or some col l ege ( 4) Col l ege degr ee( 5) Pr of essi onal or gr aduat e degr ee 

Q11. 6 Whi ch of t he f ol l owi ng best descr i bes your cur r ent mar i t al st at us?{Q11q6}: ### 

( 1) Mar r i ed( 2) Wi dowed( 3) Di vor ced

( 4) Separat ed( 5) Remarr i ed( 6) Never marr i ed

Q11. 7 Whi ch of t he f ol l owi ng best descr i bes your r aci al backgr ound?{Q11q7}: ###

( 1) Caucasi an ( 2) Af r o- Ameri can( 3) Hi spani c ( 4) Asi an/ Or i ent al or Paci f i c I sl ander  ( 5) Ot her ( pl ease expl ai n on t he l i ne bel ow{Q11q7ot h}:  

Q11. 8 What i s t oday' s date? {Q11q8}: