The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.
Interval Questions for Patients, Parents and Caregivers
Life isn’t always easy. If there's a problem, we may be able to help.
We’re asking all patients and caregivers about problems that affect many families. These problems could affect your health or that of your loved ones. You will not be judged by your answers so please be as honest as you can. You can answer any or all the questions as you see best. Your answers are private. It will only be shared with the provider.
If you are a parent or caregiver, please complete the following two questions:
Your information will be encrypted.
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