CHQ-PF50

CHILD HEALTH QUESTIONNAIRE

YOUR CHILD'S GLOBAL HEALTH - SECTION 1
Q1.1 In general, would you say your child's health is:
{Q1q1}: ### (1) Excellent
(2) Very Good
(3) Good
(4) Fair
(5) Poor
YOUR CHILD'S PHYSICAL ACTIVITIES - SECTION 2
Q2.1 During the past four weeks, has your child been limited
in any of the following activities due to health problems?
(1) Yes, limited a lot.
(2) Yes, limited some
(3) Yes, limited a little.
(4) No, not limited.

{Q2q1b}: ###
{Q2q1c}: ###
{Q2q1d}: ###
{Q2q1e}: ###

{Q2q1a}: ### Doing things that takes a lot of

energy such as playing soccer or running?
Doing things that takes some energy such as riding a
bike or skating?
Ability (physically) to get around the neighborhood,
playground, or school?
Walking one block or climbing one flight of stairs?
Bending, lifting, or stooping?
{Q2q1f}: ### Taking care of him/herself, that is,
eating, dressing, bathing, or going to the toilet?

YOUR CHILD'S EVERYDAY ACTIVITIES - SECTION 3

Q3.1 During the past four weeks, has your child's school
work or activities with friends been limited in any of the
following ways days to EMOTIONAL difficulties or problems
with his/her BEHAVIOR?
(1) Yes, Limited a lot.
(2) Yes, limited some.
(3) Yes, limited a little.
(4) No, not limited.
{Q3q1a}: ### limited in the KIND of schoolwork or
activities with friends he/she could do
{Q3q1b}: ### limited in the AMOUNT of time he/she could spend on
school-work or activities with friends
{Q3q1c}: ### limited in PERFORMING schoolwork or
activities with friends (it took extra effort)
Q3.2 During the past four weeks, has your child's schoolwork
or activities with friends been limited in any of the
following ways due to problems with his/her PHYSICAL health?
(1) Yes, limited a lot
(2) Yes, limited some
(3) Yes, limited a little.
(4) No, not limited.
{Q3q2a}: ### limited in the KIND of schoolwork or
activities with friends he/she could do
{Q3q2b}: ### limited in the AMOUNT of time he/she could spend on
schoolwork or activities with friends
PAIN - SECTION 4
Q4.1 During the past four weeks, how much bodily pain or
discomfort has your child had? {Q4q1}: ###

(1)
(2)
(3)
(4)
(5)
(6)

None
Very mild
Mild
Moderate
Severe
Very severe

Q4.2 During the past four weeks, how often has your child had
bodily pain or discomfort? {Q4q2}: ###
(1) None of the time
(2) Once of twice
(3) A few times
(4) Fairly often
(5) Very Often
(6) Every/almost every day
BEHAVIOR - SECTION 5
Q5.1 How often during the past four weeks did each of the
following statements describe your child?
(1) Very often
(2) Fairly often
(3) Sometimes
(4) Almost never
(5) Never
{Q5q1a}:
{Q5q1b}:
{Q5q1c}:
{Q5q1d}:
{Q5q1e}:

###
###
###
###
###

argued a lot
had difficulty concentrating or paying attention
lied or cheated
stole things inside or outside the home
had tantrums or a hot temper

Q5.2 Compared to other children your child's age, in general

would you say his/her behavior is: {Q5q2}: ###
(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
WELL-BEING - SECTION 6
Q6.1 During the past four weeks, how much of the time do you
think your child:
(1) All of the time
(2) Most of the time
(3) Some of the time
(4) A little of the time
(5) None of the time
{Q6q1a}:
{Q6q1b}:
{Q6q1c}:
{Q6q1d}:
{Q6q1e}:

###
###
###
###
###

felt like crying?

felt lonely?
acted nervous?
acted bothered or upset?
acted cheerful?
SELF-ESTEEM - SECTION 7

Q7.1 During the past four weeks, how satisfied do you think
your child has felt about:
(1) Very satisfied
(2) Somewhat satisfied
(3) Neither satisfied nor dissatisfied
(4) Somewhat dissatisfied
(5) Very dissatisfied
{Q7q1a}: ### his/her school ability?
{Q7q1b}: ### his/her athletic ability?
{Q7q1c}: ### his/her friendships?

{Q7q1d}: ### his/her looks/appearance?

{Q7q1e}: ### his/her family relationships?
{Q7q1f}: ### his/her life overall?
YOUR CHILD'S HEALTH - SECTION 8
Q8.1 How true or false is each of these statements for
your child? (1) Definitely true
(2) Mostly true
(3) Don't know
(4) Mostly false
(5) Definitely false
{Q8q1a}: ### My child seems to be less healthy than other children
I know.
{Q8q1b}: ### My child has never been seriously ill.
{Q8q1c}: ### When there is something going around my child usually
catches it.
{Q8q1d}: ### I expect my child will have a very healthy life.
{Q8q1e}: ### I worry more about my child's health than
other people worry about their children's health.
Q8.2 Compared to one year ago, how would you rate your child's
health now: {Q8q2}: ###
(1) Much better now than 1 year ago.
(2) Somewhat better now than 1 year ago
(3) About the same now as 1 year ago
(4) Somewhat worse now than 1 year ago
(5) Much worse now than 1 year ago
YOU AND YOUR CHILD - SECTION 9
Q9.1 During the past four weeks, how MUCH emotional worry or
concern did each of the following cause YOU?
(1) None at all
(2) A little bit
(3) Some
(4) Quite a bit
(5) A lot
{Q9q1a}: ### Your child's physical health.
{Q9q1b}: ### Your child's emotional well-being or behavior.
{Q9q1c}: ### Your child's attention or learning abilities.
Q9.2 During the last four weeks, were you LIMITED in the amount of time
YOU had for own needs because
of: (1) Yes, limited a lot
(2) Yes, limited some
(3) Yes, limited a little
(4) No. not limited
{Q9q2a}: ### Your child's physical health?
{Q9q2b}: ### Your child's emotional well-being or behavior?
{Q9q2c}: ### Your child's attention or learning abilities?
Q9.3 During the past four weeks, how often has your child's
health or behavior:
(1) Very often
(2) Fairly often
(3) Sometimes
(4) Almost never
(5) Never
{Q9q3a}: ### limited the types of activities
you could do as a family?
{Q9q3b}: ### interrupted various everyday family activities
(eating meals, watching TV)?
{Q9q3c}: ### limited your ability as a family to "pick up and go"
on a moment's notice?
{Q9q3d}: ### caused tension or conflict in your home?

{Q9q3e}: ### been a source of disagreements or

arguments in your family?
{Q9q3f}: ### caused you to cancel or change plans (personal or
work) at the last minute?
Q9.4 Sometimes families may have difficulty getting along with
one another. They do not always agree and they may get angry.
In general, how would you rate your family's ability to get
along
with one another?
{Q9q4}: ###
(1) Excellent
(2) Very good
(3) Good
(4) Fair
(5) Poor
FACTS ABOUT YOUR CHILD - SECTION 10
Q10.1 Is your child: (1) Male

(2) Female

{Q10q1}: ###

Q10.2 Was this your first child (natural or

adopted)? {Q10q2}: ### (1) Yes
(2) No
Q10.3 What is your child date of birth? {Q10q3}: <mm/dd/yyyy >
Q10.4 What is the highest grade of school your child has
completed? (circle only one number) {Q10q4}: ###
(1) Preschool
(9) 6th Grade
(2) Kindergarten
(10) 7th Grade
(3) 1st Grade
(11) 8th Grade
(4) 2nd Grade
(12) 9th Grade
(5) 3rd Grade
(13) 10th Grade
(6) 4th Grade
(14) 11th Grade
(7) 5th Grade
(15) 12th Grade
(8) Ungraded
(16) If Ungraded, How
many years attended?
Q10.5 Have you ever been told by a teacher, school official,
doctor, nurse, or other health professional that our child has
any of the following conditions?
(1) Yes
(2) No
{Q10q5a}:
{Q10q5b}:
{Q10q5c}:
{Q10q5d}:
{Q10q5e}:
{Q10q5f}:
{Q10q5g}:

###
###
###
###
###
###
###

{Q10q5h}:
{Q10q5i}:
{Q10q5j}:
{Q10q5k}:
{Q10q5l}:
{Q10q5m}:
{Q10q5n}:
{Q10q5o}:
{Q10q5p}:
{Q10q5q}:

###
###
###
###
###
###
###
###
###
###

Anxiety problems
Asthma
Attentional problems
Behavioral problems
Chronic allergies or sinus trouble
Chronic orthopaedic, bone, or joint problems
Chronic respiratory, lung, or breathing problems
(not asthma)
Chronic rheumatic disease
Depression
Developmental delay or mental retardation
Diabetes
Epilepsy (seizure disorder)
Hearing impairment or deafness
Learning problems
Sleep disturbance
Speech problems
Vision problems
{Q10q5r}: ### Does your child have any other
chronic medical condition that is affecting
what they do or how they feel? (Please indicate
below)

FACTS ABOUT YOU - SECTION 11

Q11.1 Are you:

(1) Male

(2) Female

{Q11q1}: ###

Q11.2 What is your date of birth? {Q11q2}: <mm/dd/yyyy >

Q11.3 Which of the followint best describes your current work
status? (check all that apply)
{Q11q3a}: ### {Q11q3b}:### {Q11q3c}:### {Q11q3d}:### {Q11q3e}:###
(1) Not working due to my child's health
(2) Not working for "other" reasons
(3) Looking for work outside the home
(4) Working full or part time (either outside the home
or at a home-based business)
(5) Full time homemaker
Q11.4 Which or the following best describes your relationship
to your child?
{Q11q4}: ###
(1) Biological parent
(2) Step parent (3)
Foster parent (4)
Adoptive parent (5)
Guardian
(6) Other (please explain on the line below)
{Q11q4oth}:
Q11.5 What is
{Q11q5}:
(1)
(2)
(3)
(4)
(5)

the highest grade of school you have completed?

###
Some high school or less
High school diploma/GED
Vocational school or some college
College degree
Professional or graduate degree

Q11.6 Which of the following best describes your current marital status?
{Q11q6}: ###
(1) Married
(2) Widowed
(3) Divorced
(4) Separated
(5) Remarried
(6) Never married
Q11.7 Which of the following best describes your racial background?
{Q11q7}: ###
(1) Caucasian
(2) Afro-American
(3) Hispanic
(4) Asian/Oriental or Pacific Islander
(5) Other (please explain on the line below
{Q11q7oth}:
Q11.8 What is today's date?

{Q11q8}: <mm/dd/yyyy >