Questions from Children's Survey
Child Health Status
1. Would you say that in general CHILD's health is excellent, very good, good, fair or poor?
2. Now thinking about CHILD's physical health, which includes physical injury and illness, for how many days during the past 30 days was his/her physical health NOT good?
3. Now thinking about CHILD's mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was his/her mental health NOT good?
4. During the past 30 days, for about how many days did POOR physical or mental health prevent CHILD from doing his/her usual activities, such as play/work/recreation?

Child Unmet Needs
5. Does CHILD have any untreated problems or conditions that you think could be helped by a medical, dental, or mental health professional or counselor?
6. Does CHILD have any needs for social or family services that have not been met, such as for financial assistance, food stamps, special medical benefits or physical and sexual abuse assistance?

Child Mental Health
7. In the last 12 months, have you felt that CHILD could benefit from talking with a mental health professional about any problems he/she might be experiencing?
8. Have you or CHILD seen a health or mental health professional or talked with one about his/her concerns?
9. Do you suspect that CHILD has ever thought about committing suicide or seriously hurting himself/herself?
10. How many times during the past 12 months, if any, did CHILD witness or become involved in a violent fight or attack AT HOME where there was a good chance of serious injury to someone?

Child Health Care Coverage
11. Does CHILD have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
12. About how long has it been since CHILD had health care coverage?
13. Was there a time during the last 12 months when CHILD needed to see a doctor, but could not because of the cost?

Child Access to Care and Satisfaction
14. About how long has it been since CHILD last visited a doctor or other health care provider, such as a physician's assistant, or a clinical nurse specialist FOR A ROUTINE CHECKUP?
15. About how long has it been since CHILD last visited a doctor or other health care provider FOR ANY REASON including a check-up or because he/she was ill?
16. How would you rate your satisfaction with CHILD'S overall health care? Would you say excellent, very good, good, fair, or poor?
17. Is there one particular clinic, health center, doctors office, or other place that CHILD usually goes to if he/she is sick or advice is needed about his/her health?
18. Is there one of these places that CHILD goes to most often when he/she is sick or advice is needed about his/her health?
19. Thinking of the distance or time you travel to get to the place CHILD usually goes to, how would you rate the convenience of that place? Would you say excellent, very good, good, fair, or poor?

Child Oral Health and Dental Care Coverage
20. About how long has it been since CHILD last visited the dentist or a dental clinic?
21. Does CHILD have any kind of insurance coverage that pays for some or all of his/her routine dental care, including dental insurance, prepaid plans such as HMOs, or government plans such as Medi-Cal?
22. Was there a time during the last 12 months when CHILD needed to see a dentist, but could not because of the cost?
23. Does CHILD currently have any untreated dental problems?

Child Weight Control and Exercise
24. Do you consider CHILD now to be overweight, underweight, or about the right weight?
25. In an average week, on how many days out of seven does CHILD get 30 minutes or more of at least moderate exercise, over the course of the entire day?
26. In an average week, on how many days, out of seven, does CHILD get aerobic exercise or participate in an aerobic activity, where CHILD'S breathing and heart rate are noticeably increased for at least 20 minutes at a time?

Child Lead Testing
27. Has CHILD ever been TESTED for lead poisoning?
28. Did the results indicate that CHILD had lead poisoning or high lead?

Child Asthma
29. Did a doctor EVER say that CHILD had asthma?
30. During the past 12 months how many episodes of asthma or asthma attacks has CHILD had?
31. How many of those episodes resulted in an emergency room visit?
32. How many of those episodes resulted in a physician office visit?

Child Tobacco Uses
33. To the best of your knowledge, does CHILD NOW smoke cigarettes every day, some days, or not at all?
34. To the best of your knowledge, how old was CHILD when he/she first started smoking cigarettes fairly regularly?
35. How many hours per day is CHILD close enough to people who are smoking that he/she can smell the smoke?

Child Alcohol Use
36. To the best of your knowledge, during the past month, has CHILD had at least one drink of any alcoholic beverage such as beer, wine, wine coolers,or liquor?
37. To the best of your knowledge, how old was CHILD when he/she first started drinking alcohol fairly regularly?

Child Nutrition
38. About how many servings of MEAT does CHILD usually eat each week?
39. How many servings of fruits and vegetables does CHILD eat each day?
40. How many servings of MILK AND DAIRY PRODUCTS does CHILD eat each day?
41. How many servings of GRAINS AND CEREALS does CHILD eat each day?
42. How often does CHILD eat AT LEAST 2 well balanced meals per day?

Child Injury Prevention
43. How often does CHILD use a car safety seat/seat belt when he/she rides in a car? Would you say always, nearly always, sometimes, seldom, or never?
44. During the past year, how often has CHILD worn a safety helmet when riding a bicycle or in-line skating?

Child Immunizations
45. Are shot records available for CHILD?
46. In your opinion, has CHILD received all of the recommended shots for CHILD'S age, including his/her D-P-T shots, which are sometimes called a diphtheria-tetanus-pertussis shot, baby shots, or three-in-one shots; Polio vaccines by mouth, pink drops or Polio shots; Measles, MMR, or Measles-Mumps and Rubella shots; H-I-B shots which are for meningitis and which is also called Haemophilus influenza; his/her Hepatitis B shots and his/her Chickenpox shots?

Parenting
47. Do any of your children under 12 participate in a day care or after-school program?

Child Sexual Activity and Drugs
48. To the best of your knowledge, has CHILD ever engaged in sexual intercourse?
49. To the best of your knowledge, in the past 12 months, how likely do you think it is that CHILD has ever used any medicines, drugs, or substances, not including alcohol, to get high or to make himself/herself feel good, WITHOUT A PRESCRIPTION or WITH GREATER FREQUENCY OR QUANTITY than prescribed? Would you say very likely, somewhat likely, a little likely, or not likely at all?
50. To the best of your knowledge, has CHILD EVER been abused sexually?

Child Health Information Issues
51. Next, please answer whether or not each of the things I mention next are areas in which CHILD might need help or additional information. What about help or information concerning how to do well in school?
52. What about help or information concerning tobacco use?
53. What about help or information concerning alcohol use?
54. What about drug use?
55. What about coping with stress?
56. What about mental health problems such as depression?
57. What about eating disorders?
58. What about dealing with gangs?
59. What about HIV or AIDS related issues?
60. What about birth control?
61. What about dealing with issues related to sexual relationships?
62. What about dealing with issues related to his/her sexual identity?
63. In general, please tell me which of the following approaches do you think would be most helpful to CHILD to get him/her the kinds of information that you think he/she needs. Written pamphlets?
64. Talking with a mental health provider or counselor?
65. Talking with a physician or other health care provider?
66. Talking with somebody associated with a religious institution?
67. Receiving information at school?
68. Receiving information in a group meeting or workshop with other children of the same age or gender?
69. Through a toll-free number?
70. Through newspapers or magazines?

* It is important to keep in mind the interrelated nature of education, income, age, and ethnicity and their impact on health status. The lower the socioeconomic status of the person, the more likely he or she will have poorer health status. The lower the education of the person, the more likely he or she will be lower income, and the more likely he or she will have poorer health status. The extent to which any specific group tends toward lower socioeconomic status, the lower the health status of that subgroup is likely to be.