1 2 early teen questionnaire for parents · this section asks about your relationship with your...

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Early Teen Questionnaire—for Parents

Thank you for continuing to be a part of Project Viva! We’ve included some new questions this year that we think you will find interesting,

plus a few you’ve seen before.

Please complete this Early Teen Questionnaire. If you are unable to complete this

questionnaire at the visit, please complete it within a week and mail it in the large pre-

stamped envelope to:

Project Viva

Harvard Pilgrim Health Care Institute

PO Box 15710

Boston, MA 02215

Please note:

This questionnaire is about your child, __________________________.

When we refer to “your child,” please respond with this child in mind.

This questionnaire will take approximately 20 minutes to complete.

Read each question carefully and answer it as best as you can.

Your answers will be kept completely confidential. We use a study identification

number instead of your name on all of our forms.

If you have any questions, please feel free to call us at (800) 598-4247, ext. 86067, or email us at [email protected].

I. STUDY NUMBER___________________

II. EVENT ____________

II. TODAY’S DATE __ __ / __ __ / __ __

III. RA INITIALS ____ ____ ____

IV. 1 SA 2 IA

3 OTHER

3 OTHER

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We know that some families have changed in the dozen years since Project Viva started. We would prefer that the mother who has participated in Viva since pregnancy be the one to fill out the questionnaire, but recognize that this may not be possible in some circumstances. Therefore, we would like to know your relationship to the child named on the cover page. O1. Are you the mother of the child named on the cover page who has participated in

Project Viva since pregnancy?

1 Yes (SKIP to A1)

2 No

SECTION A: HOME ENVIRONMENT This first section is about the home where your child usually sleeps at night. A1. Do you and your child live in the same home as each other?

1 Yes

2 No (SKIP to SECTION B on page 5)

A2. Which of the following best describes the building in which you live? Include all apartments, flats, etc., even if vacant.

1 A one-family house detached from any other houses

2 A one-family house attached to one or more houses

3 A building with 2 or 3 apartments

4 A building with 4 or more apartments

5 Other

i) What is your relationship to this child?

1 Stepmother

2 Father

3 Stepfather

4 Other,

Specify: ________________________

ii) What is your date of birth?

____ ____ / ____ ____ /____ ____ ____ ____

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A3. Counting yourself, how many adults (persons 18 and older) live in your home? ___ ___ adults

a) How many of these adults currently smoke? ___ ___ adults currently smoke A4. How many children under the age of 18 live in your home, including your child?

___ ___ children under age 18

a) How many of these children currently smoke?

___ ___ children currently smoke

A5. In the past 12 months, have you ever used any of the following in the room where your

child sleeps? Yes No

a) A room air conditioner 1 2

b) Central air conditioner 1 2

c) A dehumidifier 1 2

d) A humidifier or vaporizer 1 2

A6. Is there any moisture or mildew anywhere in your home on the…

Yes No

Don’t Know

a) Ceiling 1 2 9

b) Walls 1 2 9

c) Windows 1 2 9

A7. In the past 12 months, has there been water damage to the building or its contents (for example, from broken pipes, leaks, or a flood)?

1 Yes

2 No

9 Don’t know

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A8. In the past 12 months, has water collected on the basement floor?

1 Yes

2 No

9 Don't know

A9. In the past 12 months, have you seen or noticed signs of any of the following in your

home?

Yes No Don’t Know

a) Cockroaches 1 2 9

b) Rats or mice 1 2 9

A10. In the past 12 months, have you owned…?

Yes No

a) A dog 1 2

b) A cat 1 2

c) Another furry pet, for example, gerbil, hamster, guinea pig or rabbit 1 2

d) A bird 1 2

e) Some other pet, for example, fish 1 2

A11. Do you currently smoke cigarettes?

1 Yes

2 No

a) In the past month, on average, how many cigarettes per day have you smoked?

1 Less than 1 cigarette per day

2 1 to 4 cigarettes per day



5 25 cigarettes or more per day

b) On average, how many cigarettes per day do

you smoke in your home? (1 pack=20 cigarettes) ___ ___ cigarettes/day smoked in home

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A12. Does anyone other than yourself smoke within your home? Include regular visitors, for example a grandparent or babysitter.

1 Yes

2 No

9 Don't know

A13. In the past 12 months, on average, how many hours per week has your child been exposed to

cigarette smoke? Please include time spent at home and elsewhere.

1 0 hours per week

2 Less than 1 hour per week

3 1 to 4 hours per week



6 More than 12 hours per week

SECTION B: YOUR HEALTH Excellent

Very Good

Good Fair Poor

B1. In the past month, in general, would you say your health is:

1 2 3 4 5

B2. In the past month, on average, how many hours per week have you spent ...

a) Watching TV shows or movies?

___ ___ hours per week b) Walking (include walking for fun or exercise and walking to work, but not walking

at work)?

___ ___ hours per week

a) On average, how many cigarettes per day do others smoke in your home? (1 pack=20 cigarettes)

___ ___ cigarettes /day smoked in home

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B3. In the past month, on average, how many hours per week have you spent engaged in… a) Light or moderate recreational activities or sports such as bowling, yoga, stretching

classes, skating, biking, gardening, vacuuming or other similar activities? (Do not include walking.)


b) Vigorous recreational activities or sports such as running, swimming, cycling,

aerobics, skiing, heavy yard work or other similar activities?

___ ___ hours per week B4. In the past month, on average, how often did you eat something from a fast food restaurant

such as McDonald’s, Burger King, Taco Bell, Dunkin Donuts or a pizza place?

1 Never/less than once per month

2 1 – 3 times per month

3 Once per week

4 2 – 4 times per week

5 5 – 6 times per week

6 Once per day or more

B5. How much do you weigh now?

__ __ __ 1 pounds

OR

__ __ __ 2 kilograms

B6. In the past month, on average, how many hours per day did you sleep in a usual 24-hour

period? (Answer separately for weekdays and for weekend days).

a) ____ ____ hours per day on a weekday b) ____ ____ hours per day on a weekend day

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B7. In the past month, how often did you snore?

1 Every night

2 Most nights

3 A few nights a week

4 Occasionally

5 Almost never

6 Don’t know B8. How old were you when you had your first menstrual period?

___ ___ years old B9. Have your menstrual periods stopped permanently (that is, no periods for at least the past

12 months and not due to birth control)?

1 Yes

2 No

SECTION C: YOUR HOUSEHOLD C1. During the past 12 months, what was the total income of your household before taxes?

Please include money from all sources such as salaries, tips, Social Security, Transitional AFDC (TAFDC), retirement, and any other kind of support. Per Year Per Month Per Week

1 $10,000 or Less = $833 or Less = $192 or Less

2 10,001 to 20,000 = 834 to 1,666 = 193 to 384

3 20,001 to 40,000 = 1,667 to 3,333 = 385 to 769

4 40,001 to 70,000 = 3,334 to 5,833 = 769 to 1,346

5 70,001-100,000 = 5,834 to 8,333 = 1,347 to 1,923

6 100,001-150,000 = 8,334 to 12,500 = 1,924 to 2,884

7 More than 150,000 = more than 12,501 = more than 2,885

9 Don’t know

a) Why did your periods stop?

1 Natural

2 Surgical (hysterectomy)

3 Radiation or chemotherapy

b) How old were you when your periods

stopped? ___ ___ years old

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C2. In the past five years, have you received public assistance, received welfare, or lacked basic necessities (such as food, rent, or medical care)?

1 Yes

2 No

9 Don’t know

C3. In the past five years, have you or your family qualified for or received food stamps,

reduced or free lunch, or food from a food bank?

1 Yes

2 No

9 Don’t know

C4. Which of the following best describes your current marital status? (Check only one)

1 Married

2 Not married, but living with a partner

3 Never married

4 Divorced

5 Separated

6 Widowed

C5. What is your current employment status? (Check all that apply)

A Employed full-time (at least 35 hours per week)

B Employed part-time (less than 35 hours per week)

C Employed, but currently on maternity/medical leave

D Not employed, looking for work

E Not employed, not looking for work

F Student (either full-time or part-time)

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SECTION D: YOU AND YOUR CHILD This section asks about your relationship with your child. Remember, when we refer to “your child”, we mean your child named on the cover page. D1a. Do you have a household rule for how much time your child can watch TV in a day?

1 Yes 2 No (SKIP to D1b)

D1b. Do you have a household rule for how late your child can stay up at night?

1 Yes 2 No (SKIP to D1c)

i) Do you enforce this rule?

1 No, because my child follows it anyway (SKIP to D1b)

2 No, for some other reason (SKIP to D1b)

3 Yes

ii) How often do you enforce this rule?

Less than half the time

About half the time

Most of the time All of the time

2 3 4 5


1 No, because my child follows it anyway (SKIP to D1c)

2 No, for some other reason (SKIP to D1c)

3 Yes



About half the time


2 3 4 5

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D1c. Do you have a household rule for how much candy, sweets, or other snacks your child eats?

1 Yes 2 No (SKIP to D1d)

D1d. Do you have a household rule for which children your child can spend time with?

1 Yes 2 No (SKIP to D2)

D2. In the past month, how often have you…

Not in the

past month 1 or 2 times in the past

month

About once a week

Several times a week

Every day

a) Hugged your child or showed physical affection (kiss, stroke hair, etc)

1 2 3 4 5

b) Told your child that you love him/her? 1 2 3 4 5

c) Told your child you appreciated something he/she did?

1 2 3 4 5

d) Talked with your child about his/her day?

1 2 3 4 5

e) Spent time with your child doing one of his/her favorite activities?

1 2 3 4 5


1 No, because my child follows it anyway (SKIP to D1d)

2 No, for some other reason (SKIP to D1d)

3 Yes



About half the time


2 3 4 5


1 No, because my child follows it anyway (SKIP to D2)

2 No, for some other reason (SKIP to D2)

3 Yes



About half the time


2 3 4 5

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SECTION E: YOUR CHILD’S HEALTH

These next set of questions are about your child’s health. Please remember, when we refer to “your child,” we mean your child named on the cover page.

Excellent Very Good

Good Fair Poor

E1. In general, would you say your child’s health is: 1 2 3 4 5

E2. Has your child had his/her tonsils or adenoids removed?

1 Yes

2 No

E3. How would you classify your child’s current weight?

1 Underweight

2 Normal weight

3 Overweight

4 Obese

E4. We are interested in your child’s height and weight. Was your child measured today by Project Viva Staff?

1 Yes (SKIP to E5)

2 No

a) At what age were your child’s tonsils or adenoids removed? ___ ___ years old

Please answer the following questions based on the last time he/she was measured.

a) What was your child’s weight?

___ ___ ___ lbs

b) What was your child’s height?

___ ft ___ ___ inches

c) In what month and year were these measurements taken?

___ ___ /___ ___ ___ ___ M M Y Y Y Y

d) Where were these measurements taken? 1 Home 3 Pediatrician’s office

2 School 4 Other location:

______________________

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E5. In the past 12 months, have you been told by a health care professional (such as a doctor, physician assistant or nurse practitioner) that your child is…

a) Overweight or obese? 1 Yes 2 No 3 My child has not been to the

doctor in the past 12 months. b) Underweight? 1 Yes 2 No 3 My child has not been to the

doctor in the past 12 months. E6. In the past 12 months, how often has your child tried to lose weight?

1 Never

2 Rarely

3 Sometimes

4 Often

9 Don't know

E7. How important is it to you that your child:

Not at all important

A little Somewhat Very

important

a. Be thin? 1 2 3 4

b. Not be fat? 1 2 3 4

E8. I think that my child...

1 is just about the right weight.

2 should gain weight.

3 should lose weight.

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The following questions are about your child's pubertal development. We understand that your child may not have begun to enter the stages of puberty and will repeat these questions over the next few years to capture the start of puberty for every child.

If your child is a BOY,

please answer questions E9 and E10.

If your child is a GIRL,

please answer questions E11 and E12.

E9. Have you noticed a deepening of your son’s voice?

1 Voice has not yet started changing

2 Voice has barely started changing

3 Voice changes are definitely underway

4 Voice changes seem complete

9 I don't know

E10. Has your son begun to grow any facial

hair?

1 Facial hair has not yet started growing

2 Facial hair has barely started growing

3 Facial hair growth has definitely started

4 Facial hair growth seems complete

9 I don't know

(PLEASE SKIP to QUESTION E13, PAGE 13)

E11. Have you noticed that your daughter’s breasts have begun to grow?

1 Breasts have not yet started

growing

2 Breasts have barely started growing

3 Breast growth has definitely started

4 Breast growth seems complete

9 I don't know

E12. Has your daughter ever had a menstrual

period?

1 Yes

2 No (SKIP to E13)

a) When was your daughter’s first

menstrual period?

___ ___ / ___ ___ ___ ___ M M Y Y Y Y

E13. Would you say that your child's body hair growth... ("Body hair" means hair any place other than the head, such as under the arms)

1 Has not yet begun

2 Has barely started

3 Is definitely underway

4 Seems completed

9 I don't know

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E14. Would you say that your child's growth spurt in height...

1 Has not yet begun

2 Has barely started

3 Is definitely underway

4 Seems completed

9 I don't know

E15. Have you noticed any changes to your child's skin, especially pimples?

1 Skin has not yet started changing

2 Skin has barely started changing

3 Skin changes are definitely underway

4 Skin changes seem completed

9 I don't know

E16. Is your child currently using a cream or ointment containing steroids?

1 Yes

2 No

9 Don’t know

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a) In the past 12 months, how many times has your child been…

Never Once 2-3 times More than 3

times

i) Kept out of (or sent home from) school or childcare for asthma, wheezing, or reactive airways?

1 2 3 4

ii) To doctor’s office visits for urgent treatment for asthma, wheezing or reactive airways?

1 2 3 4

iii) To the emergency room to be treated for asthma, wheezing or reactive airways?

1 2 3 4

iv) Kept in the hospital overnight for asthma, wheezing or reactive airways? 1 2 3 4

a) What was the name of the hospital? __________________________

b) In what month and year was the hospital stay?

___ ___ / ___ ___ ___ ___

M M Y Y Y Y

b) In the past month, how much of the time did your child’s asthma keep him/her from getting as much done at school or at home?

1 None of the time

2 A little of the time

3 Some of the time

4 Most of the time

5 All of the time

c) In the past month, how often has your child had shortness of breath?

1 Not at all

6 1 to 3 times a month

2 Once or twice a week

3 3 to 6 times a week

4 Once a day

5 More than once a day

E17. Have you ever been told by a health care professional (such as a doctor, physician assistant or nurse practitioner) that your child has asthma?

1 Yes 2 No (SKIP to E18, PAGE 17)

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d) In the past month, how often did your child’s asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake him/her up at night or earlier than usual in the morning?

1 Not at all

2 Once or twice

3 Once a week

4 2 or 3 nights a week

5 4 or more nights a week

e) In the past month, how often has your child used a rescue inhaler or nebulizer

medication (such as albuterol)?

1 Not at all

2 Once a week or less

3 2 or 3 times per week

4 1 or 2 times per day

5 3 or more times per day

f) In the past month, how would you rate your child’s asthma control?

1 Not controlled at all

2 Poorly controlled

3 Somewhat controlled

4 Well controlled

5 Completely controlled

g) In the past 14 days, how many days did your child have wheezing or tightness in

the chest or cough?

___ ___ days

h) In the past 14 days, how many days did your child have to slow down or stop play or activities because of cough, asthma, or wheezing or tightness in the chest? ___ ___ days

i) In the past 14 days, how many nights did your child wake up because of cough, asthma, or wheezing or tightness in the chest? ___ ___ nights

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E18. In the past month, has your child used a medication to treat breathing problems?

1 Yes 2 No (SKIP to E22, PAGE 18)

Please mark which of the following medications your child has used in the past month to treat breathing problems:

Yes No

a) Inhaled short-acting beta-agonist (For example: Albuterol, Alupent, Bricanyl, Maxair, ProAir, Proventil, Ventolin, Xoponex)

1 2

b) Nebulized beta-agonist (For example: AccNeb solution, Alupen solution, Albuterol solution, Brovana, formoterol solution, Perforomist solution, Proventil solution, Xopenex solution)

1 2

c) Long-acting beta-agonist (For example: formoterol [Foradil], salmeterol [Serevent])

1 2

d) Theophylline (For example: Slo-bid, Theo-Dur, Theobid, Uniphyl)

1 2

e) Ipratroprium bromide (For example: Atrovent) 1 2

f) Combination therapy (For example: albuterol and ipratropium bromide [Combivent])

1 2

g) Inhaled corticosteroids (For example: Aerobid, Aerospan, Asmanex, Azmacort, Flovent, Pulmicort, Pulmicort Respules, Qvar)

1 2

h) Combination inhaled corticosteroid + long-acting beta-agonist

(For example: Advair, Symbicort, Combivent) 1 2

i) Oral corticosteroids (For example: methylprednisone [Medrol], prednisone [Deltasone, Prelone, Orapred])

1 2

j) Cromolyn (For example: Intal) 1 2

k) Singulair (For example: Montelukast) 1 2

l) Nasal Steriods (For example: Vancenase, Flonase, Nasocort, Nasonex, Rhinocort, Vancerase)

1 2

m) Other medications for breathing problems

Please specify:____________________________________________ 1 2

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E19. In the past 3 days, has your child taken any medications to treat breathing problems?

1 YES 2 NO (Skip to E22) 9 Don’t know (skip to E22)

E20. In the past 72 hours, has your child taken any…

Yes No Don’t Know

a. Inhaled steroids (for example, Advair, Aerobid, Aerospan, Ashmanex, Azmacort, Flovent, Pulmicort,Pulmicort Respules, Qvar)

1 2 9

b. Nasal steroids (for example, Vancenase, Flonase, Nasocort, Nasonex, Rhinocort, Vancerase)?

1 2 9

c. Oral corticosteroids (for example, methylprednisone [Medrol], prednisone [Deltasone, Prelone, Orapred])

1 2 9

E21. In the past 24 hours has your child taken any…

Yes No Don’t Know

a. Theophylline (for example, Slo-bid, Theo-Dur, Theobid, Uniphyl))?

1 2 9

b. Long-acting beta-agonist (for example, formoterol [Foradil], salmeterol [Serevent], Brovana, formoterol solution, Performist solution)?

1 2 9

c. Leukotriene antagonist (for example, montelukast [Singulair], zafirlukast [Accolate], zileuton [Zyflo]

1 2 9

E22. In the past 12 months, has your child ever had wheezing (or whistling in the chest)?

1 Yes 2 No 9 Don’t know

a) In the past 12 months, how many attacks or episodes of wheezing has he/she had?

1 One

2 At least two, but less than one per month

3 About one every month

4 About one every week

5 Daily or nearly every day

(SKIP to E23) (SKIP to E23)

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b) In the past 12 months, has his/her chest sounded wheezy during or after

exercise or playing hard?

1 Yes

2 No

9 Don’t know

c) In the past 12 months, has his/her chest sounded wheezy breathing in cold air?

1 Yes

2 No

9 Don’t know

E23. Has your child ever had an itchy rash that was coming and going but did not completely

go away for at least 6 months?

1 Yes 2 No (SKIP to E24) 9 Don’t know (SKIP to E24)

E24. Have you ever been told by a by a health care professional (such as a doctor, physician assistant or nurse practitioner) that your child has eczema?

1 Yes

2 No

9 Don’t know

a) Has your child had this itchy rash at any time in the past 12 months?


b) In the past 12 months, has this itchy rash been in any of the following places: the folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, ears, or eyes?

1 Yes 2 No 9 Don’t know

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E25. In the past 12 months, has your child had a problem with sneezing, or a runny, or a blocked nose when he/she DID NOT have a cold or the flu?


a) In the past 12 months, has this nose problem been accompanied by itchy-watery eyes?

1 Yes

2 No

9 Don’t know

E26. In which of the past 12 months did this nose problem occur? (please check all that apply)

1 January 2 February 3 March 4 April

5 May 6 June 7 July 8 August

9 September 10 October 11 November 12 December

E27. Does this nose problem occur when your child is in the same room with a cat, dog,

disturbance of house dust, or when outdoors near freshly cut grass?

1 Yes

2 No

9 Don’t know

E28. Have you ever been told by a by a health care professional (such as a doctor, physician

assistant or nurse practitioner) that your child has hay fever or allergic rhinitis?

1 Yes

2 No

9 Don’t know

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This next question is about over-the-counter medicines, that is, medicines you can buy without a prescription. E29. In the past 12 months, how many times has your child taken each of the following? Please

count each individual dose as a single time.

Never

1 to 5 times

6 to 10 times

11 to 20 times

More than 20 times

a) Advil, Motrin, or any other ibuprofen 1 2 3 4 5

b) Tylenol or other acetaminophen, non-aspirin pain reliever 1 2 3 4 5

c) Aspirin 1 2 3 4 5

d) Aleve, or other naproxen 1 2 3 4 5

E30. Have you ever been told by a health care professional (such as a doctor, physician assistant

or nurse practitioner) that your child has Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?

1 Yes

2 No

E31. Do you consider your child to be:

1 Right-handed

2 Mostly right-handed

3 Ambidextrous (equally left- and right-handed)

4 Mostly left-handed

5 Left-handed

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SECTION F: YOUR CHILD’S DEVELOPMENT AND ACTIVITIES Please remember, when we refer to “your child,” we mean your child named on the cover page. The next questions are about the past month. Please answer them as best as you can. Include both the time your child is with you and the time your child spends away from you (for example, at school or after-school activities). F1. In the past month, on average, how many hours per day does your child spend watching

TV shows, not including DVDs or videos? Include those watched on a TV, computer, or handheld device. (Check one box for weekdays and one for weekend days.)

a) Weekdays (Mon – Fri) b) Weekend days (Sat, Sun)

1 None 1 None

2 Less than one hour per day 2 Less than one hour per day

3 At least 1, but less than 2 hours per day 3 At least 1, but less than 2 hours per day

4 2 – 3 hours per day 4 2 – 3 hours per day


6 7 or more hours per day 6 7 or more hours per day

F2. In the past month, on average, how many hours per day does your child spend watching

DVDs, videos or movies? Include those watched on a TV, computer, or handheld device. (Check one box for weekdays and one for weekend days.)


1 None 1 None






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F3. In the past month, on average, how many hours per day does your child spend playing video or computer games? Include those played on a TV, computer, or handheld device. (Check one box for weekdays and one for weekend days.)


1 None 1 None






c) Are any of these video games physically active (for example, Wii Fit, Dance Dance Revolution or Xbox Kinect)?

1 Yes

2 No

3 My child does not play video or computer games

F4. In the past month, on average, how many hours per day does your child spend on Internet-

related activities, such as social networking, email, iPhone or iPad Apps, or YouTube (not including homework or games)? (Check one box for weekdays and one for weekend days.)


1 None 1 None






F5. Is there a television set in the room where your child sleeps?

1 Yes

2 No

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F6. In the past month, on average, how many hours per week does your child spend walking (for example, to/from school, a friend's house or the store)?


F7. In the past month, on average, how many hours per week does your child spend engaged

in… a) Light or moderate recreational activities or sports such as biking, skateboarding,

dancing, gymnastics, baseball, playing outdoors, or other similar activities? (Do not include walking.)


b) Vigorous recreational activities or sports such as swimming, running, basketball, soccer, hockey, football, rollerblading, tennis, karate, or other similar activities?


F8. Does your child have a disability or condition that prevents him or her from participating

in sports or other physical activities? (Please do not include short-term illnesses or injuries.)

1 Yes (Please specify: ______________________________________)

2 No

F9. In the past month, on average, how many hours per day does your child sleep in a usual

24-hour period? (Answer separately for weekdays and for weekend days). a) ____ ____ hours per day on a weekday

b) ____ ____ hours per day on a weekend day F10. In the past month, how often does your child take naps of 10 minutes or longer?

1 Never

2 A few times per week, but not daily

3 Once a day

4 More than once a day F11. In your opinion, is your child a morning or evening person?

1 Morning

2 Evening

3 Neither

9 I don’t know

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F12. In the past month, how often has your child experienced the following during sleep?

Never Rarely Sometimes Often Don’t know

a. Breathing through mouth 1 2 3 4 5

b. Snoring 1 2 3 4 5

c. Loud snoring 1 2 3 4 5

d.

Stopping breathing or gasping or snorting for breath

1 2 3 4 5

F13. In the past month, in the 4 hours before bedtime, how often does your child have drinks

with caffeine (for example, cola, hot or iced tea, coffee, energy drinks)?

1 Never

2 Rarely

3 Sometimes

4 Often

F14. In the past month, just before bedtime how often does your child…

Never Rarely Sometimes Often

a. Drink a lot of liquids? 1 2 3 4

b. Play rough (for example: running, jumping, wrestling)? 1 2 3 4

c.

Play video games, use a computer, or watch TV (including on a handheld device, such as a cell phone or iPad)?

1 2 3 4

F15. In the past month, when your child goes to bed how often does he/she…


a. Complain about being hungry? 1 2 3 4

b. Use an electronic device for texting, instant messaging, or e-mailing. 1 2 3 4

b. Do things that keep him/her awake? 1 2 3 4

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F16. In the past month, how often does your child…


a.

Use his/her bed for things other than sleep, like playing, watching TV, or video games?

1 2 3 4

b. Have a problem with sleepiness during the day? 1 2 3 4

F17. In the past month, what time did your child usually go to bed? (Answer separately for

weekdays and for weekend days). a) On a weekday:

____ ____ : ____ ____ 1 AM

2 PM

b) On a weekend day:

____ ____ : ____ ____ 1 AM

2 PM F18. In the past month, what time did your child usually wake up? (Answer separately for

weekdays and for weekend days). a) On a weekday:

____ ____ : ____ ____ 1 AM

2 PM

b) On a weekend day:

____ ____ : ____ ____ 1 AM

2 PM

F19. In the past month, how much of a problem has your child had with…

Never Rarely Sometimes Often Always

a. Walking more than one block 1 2 3 4 5

b. Running 1 2 3 4 5

c. Participating in sports activity or exercise 1 2 3 4 5

d. Lifting something heavy 1 2 3 4 5

e. Taking a bath or shower by him or herself 1 2 3 4 5

f. Doing chores around the house 1 2 3 4 5

g. Having hurts or aches 1 2 3 4 5

h. Low energy level 1 2 3 4 5

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F20. In the past month, how much of a problem has your child had with…


a. Getting along with other children 1 2 3 4 5

b. Other kids not wanting to be his or her friend 1 2 3 4 5

c. Being teased by other children 1 2 3 4 5

d. Not being able to do things that other children his or her age can do 1 2 3 4 5

e. Keeping up when playing with other children 1 2 3 4 5

SECTION G: UPDATE ON YOUR CHILD’S DIET AND EATING HABITS

G1. Imagine that your child finished eating a meal or snack some time ago and is no longer hungry. In this situation, how often would your child start eating because:


a) Food looks, tastes or smells so good 1 2 3 4 5

b) Others are still eating 1 2 3 4 5

c) Feeling sad or depressed 1 2 3 4 5

d) Feeling bored 1 2 3 4 5

e) Feeling angry or frustrated 1 2 3 4 5

f) Feeling tired 1 2 3 4 5

g) Feeling anxious or nervous 1 2 3 4 5

G2. In the past month, has your child followed a special diet prescribed by a health care

professional?

1 Yes (Please specify: __________________________________)

2 No

G3. Please read each of the following statements and check the box that best describes your child’s eating behavior.


a) If allowed to, my child would eat too much

1 2 3 4 5

b) If given the chance, my child would always have food in his/her mouth

1 2 3 4 5

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G4. Please read each of the following statements and check the box that best describes your child’s eating behavior.

My child:


a) Loves food 1 2 3 4 5

b) Has a big appetite 1 2 3 4 5

c) Finishes his/her meal quickly 1 2 3 4 5

d) Eats slowly 1 2 3 4 5

e) Eats less when angry 1 2 3 4 5

f) Eats less when tired 1 2 3 4 5

g) Is always asking for food 1 2 3 4 5

h) Eats more when annoyed 1 2 3 4 5

i) Eats more when anxious or worried 1 2 3 4 5

j) Leaves food on the plate at the end of a meal 1 2 3 4 5

k) Takes more than 30 minutes to finish a meal 1 2 3 4 5

l) Looks forward to mealtimes 1 2 3 4 5

m) Gets full before meal is finished 1 2 3 4 5

n) Enjoys eating 1 2 3 4 5

o) Eats more when happy 1 2 3 4 5

p) Eats less when upset 1 2 3 4 5

q) Eats more when he/she has nothing else to do 1 2 3 4 5

r) Eats more and more slowly during the course of a meal 1 2 3 4 5

THANK YOU !

Please fill in today’s date:

__ __ / __ __ / __ __ __ __

MONTH / DAY / YEAR

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