Staying Healthy Assessment: 9-11 Years

Child's Name (First & Last)

Date of Birth

Sex

Female Male

Today's Date

Grade in School

Person Completing Form

Parent

Relative

Friend

Guardian

Other

If other, please specify:

School Attendance Regular?

Yes No

Need Interpreter?

Yes No

Please answer all the questions on this form as best you can. Select “Skip” if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record.

Does your child drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk, or tofu?

Yes

Skip

Does your child eat fruits and vegetables at least two times per day?

Yes

Skip

Does your child eat high fat foods, such as fried foods, chips, ice cream, or pizza more than once per week?

Yes

Skip

Does your child drink more than one cup (8oz.) of juice per day?

Yes

Skip

Does your child drink soda, juice drinks, sports drinks, energy drinks, or other sweetened drinks more than once per week?

Yes

Skip

Does your child exercise or play sports most days of the week?

Yes

Skip

Are you concerned about your child's weight?

Yes

Skip

Does your child watch TV or play video games less than 2 hours per day?

Yes

Skip

Does your home have a working smoke detector?

Yes

Skip

Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone?

Yes

Skip

Does your child always use a seat belt in the back seat (or use a booster seat if under 4’9”)?

Yes

Skip

Does your child spend time near a swimming pool, river, or lake?

Yes

Skip

Does your child spend time in a home where a gun is kept?

Yes

Skip

Does your child spend time with anyone who carries a gun, knife, or other weapon?

Yes

Skip

Does your child always wear a helmet when riding a bike, skateboard, or scooter?

Yes

Skip

Has your child ever witnessed or been a victim of abuse or violence?

Yes

Skip

Has your child been hit or hit someone in the past year?

Yes

Skip

Has your child ever been bullied, felt unsafe at school or in your neighborhood (or been cyber-bullied)?

Yes

Skip

Does your child brush and floss her/his teeth daily?

Yes

Skip

Does your child often seem sad or depressed?

Yes

Skip

Does your child spend time with anyone who smokes?

Yes

Skip

Has your child ever smoked cigarettes or chewed tobacco?

Yes

Skip

Are you concerned your child may be using drugs or sniffing substances, such as glue, to get high?

Yes

Skip

Are you concerned that your child may be drinking alcohol, such as beer, wine, wine coolers, or liquor?

Yes

Skip

Does your child have friends or family members who have a problem with drugs or alcohol?

Yes

Skip

Has your child started dating or "going out" with boyfriends or girlfriends?

Yes

Skip

Do you think your child might be sexually active?

Yes

Skip

Do you have any other questions or concerns about your child's health or behavior?

Yes

Skip

If yes, please describe:

Clinic Use Only

Nutrition

Physical Activity

Safety

Dental Health

Mental Health

Alcohol, Tobacco, Drug Use

Sexual Issues