|
| Question | Possible responses |
|
| In general how would you describe this child’s health? | Excellent; very good; good; fair; poor |
| Approximately how tall is this child? | Inches or centimeters |
| Approximately how much does this child currently weigh? | Pounds or kilograms |
| Please indicate whether a doctor or health care professional has ever told you that the child you selected (for this survey) has any of the following conditions: asthma, hay fever, skin rash or allergy, three or more ear infections, otitis media (inflammation of the middle ear), ear tubes, and tonsillectomy (had his/her tonsils removed). | Yes/no/don’t know |
| In your opinion does the child have any behavioral, emotional, or developmental problems outside of what you would consider typical for a child his or her age? | Yes/no |
| Has this child ever done any of the following? Had sleep problems. | Yes/no/don’t know |
| Please indicate how often the following items occur: people smoke cigarettes in your home. | Daily, weekly, monthly, a few times a year, seldom or never, don’t know |
| How many times did this child visit the emergency room during the past 12 months? | ———times |
| How many days did this child spend in the hospital in the past 12 months? | ———days |
| What is the primary language spoken in your household? | Spanish; English; other |
| Has this child ever done any of the following: had academic problems at school; had behavior problems at school? | Yes/no/don’t know |
| Approximately how many days of school did this child miss last year due to health problems? | ———days |
|
