Staying Healthy Assessment 9-11 years

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Child’s Name (first & last)*
Date of Birth*
Today's Date*
Today’s Date*
School Attendance Regular?

Specify if other

Please answer all the questions on this form as best you can. Circle “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.

1. Does your child drink or eat 3 servings of calcium-rich foods daily, such as milk, cheese, yogurt, soy milk, or tofu?*
2. Does your child eat fruits and vegetables at least two times per day?*
3. Does your child eat high fat foods, such as fried foods, chips, ice cream, or pizza more than once per week?*
4. Does your child drink more than one cup (8 oz.) of juice per day?*
5. Does your child drink soda, juice drinks, sports drinks, energy drinks, or other sweetened drinks more than once per week?*
6. Does your child exercise or play sports most days of the week?*
7. Are you concerned about your child’s weight?*
8. Does your child watch TV or play video games less than 2 hours per day?*
9. Does your home have a working smoke detector?*
10. Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone?*
11. Do your child always use a seat belt in the back seat (or use a booster seat if under 4’9”)?*
12. Does your child spend time near a swimming pool, river, or lake?*
13. Does your child spend time in a home where a gun is kept?*
14. Does your child spend time with anyone who carries a gun, knife, or other weapon?*
15. Does your child always wear a helmet when riding a bike, skateboard, or scooter?*
16. Has your child ever witnessed or been a victim of abuse or violence?*
17. Has your child been hit or has your child hit someone in the past year?*
18. Has your child ever been bullied, felt unsafe at school or in your neighborhood (or been cyber-bullied)?*
19. Does your child brush and floss her/his teeth daily?*
20. Does your child often seem sad or depressed?*
21. Does your child spend time with anyone who smokes?*
22. Has your child ever smoked cigarettes or chewed tobacco?*
23. Are you concerned your child may be using drugs or sniffing substances, such as glue, to get high?*
24. Are you concerned that your child may be drinking alcohol, such as beer, wine, wine coolers, or liquor?*
25. Does your child have friends or family members who have a problem with drugs or alcohol?*
26. Has your child started dating or “going out” with boyfriends or girlfriends?*
27. Do you think your child might be sexually active?*
28. Do you have any other questions or concerns about your child’s health or behavior?*