MAIN
QUESTIONNAIRE
Access to Care
- Type of Insurance Coverage
- Uninsured Adults
Alcohol and Drug Use
Barriers to Care
Elder Health
Gambling
- Adults Who Gamble
- Amount of Money Spent
- Harmful Effect on Family
Health Conditions
Health Status
Injury/Risk Prevention
- Adults Who Keep Firearms in the Home
(locked, loaded, where kept)
- Domestic Violence
- Injury due to Physical Violence
- Perceived Safety of Neighborhood
Nutrition
Other
- Alternative/Complementary Care (i.e.,
Chiropractor, Acupuncturist)
- Food Handling Practices
- Perceptions of Department of Health
Services
Physical Activity
- Adults Engaging in Any Physical Activity
- Adults Meeting Physical Activity
Guidelines
- Adults Who are Sedentary
Preventive Health
Services
- Dental Care
- Provider Discussions About Diet &
Exercise
- Screening Tests (e.g., mammogram,
cholesterol check)
Sexual Practice and HIV
Testing
- Adults Tested for HIV in Past 2 Years
- Condom Use
- Number of Partners in Past Month
Socio-Demographic-Economic
- Age
- Gender
- Educational Attainment
- Household Income
- Poverty Level/Status
- Race/Ethnicity
- U.S. Citizenship
Tobacco Use
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PARENT
QUESTIONNAIRE
Access to Care
- Reasons Why Uninsured
- Type of Insurance Coverage
- Uninsured Children
Barriers to Care
- Children Not Receiving a Physical Exam
or Immunizations
- Financial Difficulty
- Language Barrier with Provider
- Regular Source of Care
- Satisfaction with Provider
- Transportation Problems
Childcare
- Difficulty Getting Childcare and Reasons
Why
- Number of Children in Some Form of
Childcare
- Parents
Who Lost Time from Work/School due to Lack of Childcare Arrangements
- Type of Childcare and Satisfaction with
Arrangements
Child
Development/Communication
- Children Diagnosed with Attention
Deficit Disorder
- Developmental Delays and Parental
Concerns
- Parent Expectations for Child's
Educational Achievement
- Use of Evaluation and Special Services
Family and
Parent Support Services
- Home Visitation From a Nurse/Provider
After Child's Birth
- Parent
Participation in Childbirth Classes
- Receipt of Public Assistance
Health Status
- Children with Asthma
- Functional Limitations due to Health
Problem or Disability
- Parent Report of Fair/Poor Health
Injury/Risk
Prevention
- Bicycle Riding and Use of Helmet
- Households with a Swimming Pool and if
Barrier is in Place
- Seat Belt/Car Seat Use for Child
- Smoke Detectors in Home
Nutrition
- Breast Feeding Practices
- Child Ate Breakfast Yesterday
- Child Ate Fast Food Yesterday
- When Child Introduced
to Cow’s Milk
- WIC
Program Participation (during pregnancy & after child's birth)
Parental Stress
- Difficulty Coping With Demands of
Parenthood
- Parental Stress Scale
- Social Support
Parenting
Practices
- Days in Past Week Parent Read, Sang,
and/or Played Music with Child
- Infant/Child
Put to Bed with a Bottle
- Infant
Sleep Position (SIDS prevention)
- Time Child Watches Television Each Day
Preventive Health
Services
- Mothers Offered an HIV test During
Pregnancy
Social
Environment
- Easily Accessible Safe Park/Playground
Socio-Demographic-Economic
- Age
- Gender
- Household Income
- Parent's Educational Attainment
- Poverty Level/Status
- Race/Ethnicity
- U.S. Citizenship
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