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Childhood Health Assessment Questionnaire - For parents to complete

Personal Details

First name *
Please enter child's first name

Middle name
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Surname *
Please enter child's surname

Date of Birth *
/ / Please provide date of birth

Ethnicity *
Please enter child's ethnicity

GP Name
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Name of person completing form *
Please input your name

Address line 1 *
Please enter first line of child's address

Address line 2 *
Please enter second line of child's address

Address line 3
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Town
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Postcode *
Please enter child's postcode

GP Surgery
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Relationship to Child *
Please select one option

Relationship to child (other)
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Contact details

Mobile Phone No
Please input valid mobile phone number

Home Phone No
Please input valid home phone number

Work Phone No
Please input valid work phone number

Email address *
Please enter email address

Preferred Contact Method *
Please enter preferred method of contact
 

Questionnaire

We are interested in hearing how your child's illness affects his/her ability to function in daily life. In the following questions, please tick the one response which best describes his/her usual activities OVER THE PAST WEEK. ONLY NOTE THOSE DIFFICULTIES OR LIMITATIONS WHICH ARE DUE TO ILLNESS. If most children at your child's age are not expected to do a certain activity, please mark it as 'not applicable'. For example if your child has difficulty in doing a certain activity or is unable to do it because he/she is too young, but not because he/she is RESTRICTED BY ILLNESS, please mark it as 'not applicable'
In the end, please go back and check once again that every item has been answered.

Dressing & Personal Care

Is your child able to dress, including tying shoelaces and doing buttons? *

Please select one answer

Is your child able to shampoo his/her hair? *

Please select one answer

Is your child able to remove his/her socks? *

Please select one answer

Is your child able to cut his/her fingernails? *

Please select one answer

Getting Up

Is your child able to stand up from a low chair or floor? *

Please select one answer

Is your child able to get in and out of bed *

Please select one answer

Eating

Is your child able to cut his/her own meat? *

Please select one answer

Is your child able to lift a cup or glass to his/her mouth? *

Please select one answer

Is your child able to open a new cereal box? *

Please select one answer

Walking

Is your child able to walk outside on flat ground? *

Please select one answer

Is your child able to climb up five steps? *

Please select one answer

Hygiene

Is your child able to wash and dry their entire body? *

Please select one answer

Is your child able to take a bath (get in and get out)? *

Please select one answer

Is your child able to get on and off the toilet? *

Please select one answer

Is your child able to brush his/her teeth? *

Please select one answer

Is your child able to comb or brush his/her hair? *

Please select one answer

Reach

Is your child able to reach and get down a heavy object such as a large game or books from just above his/her head? *

Please select one answer

Is your child able to bend down to pick up clothing or a piece of paper from the floor? *

Please select one answer

Is your child able to pull on a jumper over his/her head? *

Please select one answer

Is your child able to turn his/her neck to look back over his/her shoulder *

Please select one answer

Grip

Is your child able to write with pen or pencil? *

Please select one answer

Is your child able to open car doors? *

Please select one answer

Is your child able to open jars which have been previously opened? *

Please select one answer

Is your child able to turn taps on and off? *

Please select one answer

Is your child able to push open a door when they have to turn a door knob? *

Please select one answer

Activities

Is your child able to run errands and shop? *

Please select one answer

Is your child able to get in an out of a car or school bus? *

Please select one answer

Is your child able to ride a bike or a tricycle? *

Please select one answer

Is your child able to do household chores eg wash dishes, take out rubbish, hoovering, gardening, make bed, clean room? *

Please select one answer

Is your child able to run? *

Please select one answer

Aids or Devices

Please tick any AIDS or DEVICES that your child usually uses for any of the above activities:

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Please detail any AIDS or DEVICES not covered in the check boxes above
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Help Required

Please tick any categories for which your child usually needs help from another person BECAUSE OF PAIN OR ILLNESS:

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Pain

How much pain do you think your child has had IN THE PAST WEEK?
This is on a scale of 0 to 100 where 0 = No Pain and 100 = Very severe pain
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General Evaluation

Considering all the ways that arthritis affects your child, rate how he/she is doing.
This is on a scale of 0 to 100 where 0 = Very well and 100 = Very poor
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