Child Health Survey

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0

Rate your child’s behavior according to the following aspects:

Not at all

Extremely

Friendliness

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Cooperation

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Kindness

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Empathy

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Patience

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Well-mannered

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely
0

In general, how healthy would you say your child is?
Not at all

Slightly

Moderately

Very

Extremely
0

Has your child ever complained of pain or discomfort?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child ever been prevented from doing physical activities due to health problems?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child ever had problems with friends or family due to emotional problems or behavioral difficulties?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child had bodily pain or discomfort for an extended period of time?
No

Yes
0

Please elaborate

0 / 5000
0

How well-socialized is your child?
Not at all

Slightly

Moderately

Very

Extremely
0

How often does your child complain of fatigue?
Never

Rarely

Sometimes

Often

Always
0

In general, how well does your family get along with one another?
Not at all

Slightly

Moderately

Very

Extremely

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0

Rate your child’s behavior according to the following aspects:

Not at all

Extremely

Friendliness

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Cooperation

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Kindness

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Empathy

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Patience

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely

Well-mannered

Not at all

Extremely

1 Not at all

2

3

4

5 Extremely
0

In general, how healthy would you say your child is?
Not at all

Slightly

Moderately

Very

Extremely
0

Has your child ever complained of pain or discomfort?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child ever been prevented from doing physical activities due to health problems?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child ever had problems with friends or family due to emotional problems or behavioral difficulties?
Yes

No
0

Please elaborate

0 / 5000
0

Has your child had bodily pain or discomfort for an extended period of time?
No

Yes
0

Please elaborate

0 / 5000
0

How well-socialized is your child?
Not at all

Slightly

Moderately

Very

Extremely
0

How often does your child complain of fatigue?
Never

Rarely

Sometimes

Often

Always
0

In general, how well does your family get along with one another?
Not at all

Slightly

Moderately

Very

Extremely

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