Development of the Child Health Indicator Assessment (CHIA) in a Community-Based Nurse-Managed Center

By Sligar, Kristen; Savitz, Molly; Schapiro, Naomi A; Alkon, Abbey; Et al

A team comprised of one nurse administrator, three nurse clinicians, and two nurse researchers developed the Child Health Indicator Assessment (CHIA), an assessment tool that monitors all 10 of the Healthy People 2010 Leading Health Indicators in a pediatric nurse-managed practice. The CHIA is a survey to be administered in a clinic setting, which facilitates regular health maintenance history- taking on 10 key health indicators and provides annual prevalence data on the health of one clinic-based population. CHIA Part A solicits parent or adolescent self-report data at routine health supervision visits. CHIA Part B is completed by a nurse practitioner after the well child visit and includes information collected from chart review. The survey development process presented several challenges but resulted in an easy-to-use, clinically relevant instrument. The data from the CHIA will be used to guide clinic- wide interventions to improve and promote pediatric health in two key areas each year.

Childhood is a period of rapid growth and development that makes children both uniquely sensitive and remarkably resilient to physical and environmental insults. As such, pediatric health care, unlike that of adults, remains focused on health promotion and disease prevention and is well suited to nurse-managed care (Humphreys, Martin, Roberts, & Ferretti, 2004). Pediatric nurse- managed care seeks to promote child health and development and to support the establishment of behaviors that will sustain health for a lifetime. However, to accomplish these goals, advanced practice nurses must continuously monitor patients’ changing needs and have access to comparable data against which these needs can be measured. The comprehensive national goals of Healthy People 2010 (U.S. Department of Health and Human Services [USDHHS], 2000) offer such a standard. Healthy People 2010 provides 10 Leading Health Indicators (LHI), chosen by the USDHHS for their relevance to public health, their ability to motivate action, and their potential to be measured (see Table 1). The LHI are of particular relevance to pediatric healthcare as early intervention in many of these areas can make a critical difference in outcomes (Clotfelter, Pohl, & Guthrie, 1999; Haire-Joshu & Nanney, 2002).

Assessment of pediatric patient health status and behaviors can be difficult, however. Seid, Varni, and Kurtin (2000) and others (Forrest, Simpson, & Clancy, 1997) advocate that measures of morbidity alone in pediatric primary care are inappropriate and inadequate. They note that the assessment of children requires a comprehensive view of health that considers their ongoing development and functioning in multiple domains, retains a focus on preventive services, and considers children’s dependency on adults and on other systems. The need for comprehensive, developmentally- sensitive, wellness-oriented assessment also must be counterbalanced with the need to develop measures that are short, practical, and solicit parent or self-report data (McGlynn & Halfon, 1998). Some clinic-specific data can be retrieved from managed care plans and public insurance programs, but these data are limited to a few objective measurements (e.g., heights, weights, hemoglobin levels) and apply only to the segment of the clinic population with those payer sources. The collection of information on health behaviors, typically by survey, usually is done with large samples of adolescents in school settings (California Healthy Kids Survey [CHKS], 2005, Centers for Disease Control and Prevention [CDC], 2004) or with parents by telephone (Simmons, Shalwitz, Pollock, & Young, 2003). However, an extensive search of the literature revealed no published reports of instruments designed to measure child health status using Healthy People 2010 indicators in pediatric primary care settings.

The purpose of this article is threefold: (1) to describe the process undertaken to develop the CHIA, a survey that facilitates regular health maintenance history-taking on 10 key health indicators, (2) to describe the assessment tool, and (3) to report on the implementation of the CHIA in a pediatric community-based nursemanaged academic health center.

Setting

Nurse-managed centers provide patients with care that is delivered and managed by nurses. This care is holistic, patient- centered, and committed to health promotion and disease prevention (Anderko, Robertson, & Uscian, 2000). Valencia Health Services (VHS) is a nurse-managed, community-based, state-licensed pediatric primary care clinic serving a medically underserved, minority community in San Francisco (Humphreys et al., 2004). VHS is administered by the UCSF Department of Family Health Care Nursing, and provides services in collaboration with San Francisco State University School of Nursing. As an academic health center, VHS strives for excellence through providing health care to the underserved, educating health professionals, and conducting research that advances community health.

Instrument Development

In 2002, an ad hoc committee was formed to develop an assessment tool that would balance the clinicians’ need for brevity and for relevance to annual health maintenance historytaking with the essential data necessary to monitor 10 key pediatric health indicators (USDHHS, 2000). The committee included four VHS nurse practitioners (three clinical faculty and the clinical director), a nurseepidemiologist, and the Project Director. The group addressed broad topics such as the overall goals of the tool and data collection, the minutia of survey question and answer language, and the format of forms. Planning began in October 2002, and the tool was implemented in April 2004.

The original survey goal was to collect data that would describe the VHS patient population at baseline and to measure change over time at the population level. While considering the content, the committee also realized the importance of developing a tool that was not redundant to history forms for well child visits or to other required paperwork patients complete at the clinic. An implementation plan had to be designed that would not burden the support staff or impede clinic flow. Additional concerns were insuring patient privacy and adhering to HIPAA compliance in data collection. These will be discussed further below.

The intent of the CHIA is to assess pediatric health status and behaviors, to gather data to describe the patient population, and to guide health maintenance discussions. Faced with the challenge of creating an assessment and research tool that was both comprehensive and brief enough to use in the clinic setting, the committee considered each of the 51 pediatric objectives under the 10 LHI. These objectives were grouped into three categories: (1) information that would be identified by patient or parent questionnaire (CHIA Part A), (2) information that would be identified by chart review (CHIA Part B), and (3) information that the committee believed could not be collected or was too difficult to measure in this setting (see Figure 1). Thirty objectives fell into the first category and included, for example, assessment of the number of fruits and vegetables consumed in a day, frequency of seatbelt use, and exposure to tobacco smoke. Fourteen objectives would be identified by chart review, including identification of children who are overweight and those with elevated lead levels. Finally, seven objectives were determined by the committee to be too difficult to measure, such as differentiating between participation in moderate versus vigorous physical activity and individuals living in pre- 1950′s housing with lead-based paint.

CHIA Part A: Parent-or Adolescent-Report Data. Considerable attention and discussion were focused on how to ask the instrument questions. To collect data that could be directly compared with findings from other sites, the committee sought to preserve the language of Healthy People 2010 as much as possible. In addition, tools from other organizations such as the California Healthy Kids Survey (CHKS, 2005) and the Youth Risk Behavior Survey (YRBS) (CDC, 2004) were considered. The language of the CHIA was carefully chosen and refined in an attempt not to exceed a sixth grade reading level. Answer choices were simplified into four-point scales (“Never”/ “Rarely”/”Sometimes”/”Often” or “Never”/”Sometimes”/”Mostly”/ “Always”) to collect data that could measure change over time.

To assure that parent and selfreport items are developmentally relevant to the patient, four versions of the CHIA Part A were generated (0-1 year, 1-3 years, 4-11 years, 12 years and older). Parents of children less than 12 years of age complete CHIA Part A for the child, while adolescents complete the questionnaire independently. Each age-specific questionnaire was piloted with a clinic staff member who was a parent of a child of the appropriate age range, or with an adolescent. Feedback from piloting resulted in further clarification of language and forma\t.

To facilitate comparisons across developmental groups, LHI are assessed using the same question on each of the four versions of the CHIA Part A whenever appropriate. For example, the LHI for environmental quality is assessed in every CHIA Part A by the following question: “Does your home have adequate heat, electricity, and plumbing?” Other LHI are assessed only in older children, such as the use of bicycle helmets by those ages four and older. For adolescents, more detailed questions are also included on several topics. For example, assessment of young children’s exposure to tobacco is limited to an inquiry: “How often does your child spend time in a place where someone smokes?” In contrast, adolescents are asked questions not only about smoke exposure, but also about their own smoking habits and attempts to quit. The inclusion of more detailed ageappropriate questions resulted in instruments of increasing length by age (the number of questionnaire items ranges from 9 for the 0-1 yearold version to 26 for the 12 year and older version) and additional time needed for completion. Despite these differences, the tool remains quick and easy to complete for most clients. On average, completion by parents takes 3 to 5 minutes and approximately 5 to 10 minutes for adolescents.

Generating questions to assess individual LHI varied in difficulty. The assessment of some items was relatively straightforward (e.g., “When your child rides a bike, scooter, or skateboard, does he/she wear a helmet?”), while other areas required greater insight and creativity. This often involved deciding how to ask questions of a potentially sensitive nature to gather meaningful data. Two of these areas are described in more detail.

One of the goals of Healthy People 2010 is to promote responsible sexual behavior. In California, adolescents currently have the right to have confidential discussions with their health care providers about pregnancy and contraception with no specified age limits, and from age 12, have the right to confidential discussions about sexually transmitted infections and alcohol, tobacco and other drug use (Simmons et al., 2003). In the 2000 edition of Healthy People 2010, a goal also was set to eliminate health disparities between different segments of the population, including “differences that occur by gender, race or ethnicity, education or income, disability, geographic location or sexual orientation” (USDHHS, 2000). Sieving, Olipant, and Blum (2002) suggest that adolescents are most likely to respond honestly to open-ended, nonjudgmental questions about sexuality. Because the CHIA Part A is multiple choice, it was decided to approach questions about sexuality by including more choices and a broader definition of sexual activity than either the CHKS (CHKS, 2005) or the Guidelines for Adolescent Preventive Services (GAPS) questionnaire (Elster & Kuznets, 1994), both of which ask about “sexual intercourse.” The wording of the CHIA question was taken from the 1999 Massachusetts and Boston versions of the YRBS (as cited in Sell & Becker, 2001): “During your life, the person(s) you have ever had sexual contact with is (are)…” Adolescents are asked to select from the following four choices: “I have not had sexual contact with anyone,”"females,”"males,” or “males and females.” This question, along with additional CHIA items about condom use and forced or pressured sex, was believed to allow clearer identification of those adolescents at risk for unintended pregnancy and sexually transmitted infections, as well as to provide an opening to further discussion with patients.

Assessment of child and adolescent exposure to and use of tobacco also were discussed at length. A significant body of literature has demonstrated that exposure to environmental tobacco smoke is detrimental to child health (DiFranza, Aligne, & Weitzman, 2004; Hofhuis, de Jongste, & Merkus, 2003). The Healthy People 2010 goals acknowledge the toll of smoke exposure and specify at least two objectives related to children (USDHHS, 2000), yet none of the major health surveys the committee reviewed assessed exposure of children to environmental tobacco smoke (CDC, 2004; California Health Interview Survey, [CHIS], 2001, 2003; CHKS, 2005). In developing the CHIA, the committee recognized that it was important not only to question parents about their own smoking behaviors, but also to find out if there are other sources of environmental tobacco smoke in the children’s lives. The CHIA therefore phrases the question, “How often does your child spend time in a place where someone smokes?” allowing for the collection of information about smoking by grandparents, non-custodial parents, friends, and others.

Because efforts to decrease tobacco use involve individual smokers’ readiness for change (Kearney & O’Sullivan, 2003), each version of the parent- and adolescent-report CHIA includes the question, “If you smoke, how many times have you tried to quit in the last year?” While the core module of the CHKS (2005) and another major statewide health survey (CHIS, 2001 & 2003) do not include this line of questioning, the current YRBS (CHKS, 2005) does assess smoking cessation attempts by high school students with “yes”/”no” answer options. The CHIA committee felt that quantifying cessation attempts would be helpful in gauging parents’ and adolescents’ receptiveness to counseling and referrals (Hymowitz et al., 1997). Furthermore, all CHIA questions regarding tobacco use refer only to “smoking,” requiring the clinician to clarify a positive response – does the parent or adolescent smoke cigarettes, cigars, marijuana, or something else?

Once the language of the tools was edited and finalized, each tool was translated to accommodate the Spanish-speaking parents and patients who comprise approximately 35% of the clinic clientele. This process also presented more challenges than expected. The initial effort by a translator originally from Puerto Rico contained words and syntax that were unfamiliar to the majority of the clinic’s clientele from Mexico and Central America, as well as a number of inconsistencies in terminology and phrasing. The CHIA committee worked with bilingual clinic staff to resolve these issues, during which time the Spanish version of the tools also was pilot tested.

CHIA Part B: Clinician Chart Review. The CHIA Part B is a chart review form used to collect objective data on areas not thoroughly addressed in the parent or self-report portion of Part A. It is completed by a nurse practitioner and, like the parent or adolescent- report CHIA Part A, demanded careful design. Each item was to be collected only for those in a specific age range derived from the Healthy People 2010 guidelines (USDHHS, 2000). For example, immunization status would only be documented for children 19-35 months of age. Some information was easily retrieved, such as the proportion of overweight children and adolescents, using elevated body mass index (BMI) as a marker. Other data, however, proved more difficult to collect. For example, measuring the proportion of adolescents and young adults with chlamydia infection required data on the number who were appropriately screened, so these guidelines had to be specified for clinicians completing Part B. Determining the number of children with mental health problems receiving treatment was impossible to determine without information on screening, referral, and follow up. In developing this form, it also was recognized that because families seek care outside of the clinic, or have medical and social histories that predate their involvement with the clinic, the data collected may be incomplete in some areas. Furthermore, the definitions of vague or ambiguous items such as “mental health screening” and “maltreatment history” needed to be clarified. After several rounds of piloting, definitions and format were refined, making the chart review process more efficient.

CHIA Implementation

Once the CHIA was finalized and approved by the University of California, San Francisco Committee on Human Research (Institutional Review Board [IRB]), the plan for implementation was introduced to the clinicians and support staff, and data collection began. The front desk staff distributes a tool once a year to the parent of each patient under the age of 12 who arrives for a well-child exam. The adolescent tool is given directly to the patient by the provider in private when parent is not present. Tools are completed prior to the clinical encounter and are reviewed by the provider with the parent or adolescent. The clinician records clarifications and additional history in the chart as well as on the tool itself. This has proven to be important in distinguishing clinically relevant responses from misunderstandings or misinterpretations of the questions. For example, an adolescent who circles “Sometimes” in response to a question about frequency of having been “hit, slapped, kicked, or punched by anyone” may be referring to the behavior of a younger sibling in the household or to his roughhousing with friends. At times athletic adolescents have responded “Never” to a question about frequency of physical activity “where you are breathing hard or sweat,” because they are so fit they do not breathe hard or sweat while playing sports!

Within a few weeks of the visit, a nurse practitioner completes the CHIA Part B to collect the chart review data. To maintain complete confidentiality, the patient’s identifying information is not permanently attached to the survey until after the survey is copied for the research analyst. The research analyst enters the data into the computer database and only then does the completed tool become part of the patient chart at VHS.

Challenges

The IRB application process required careful attention to details about patient confidentiality, HIPAA compliance, and practical matters in clinic functio\ning. Initially it was believed that collected data could be quickly turned over to the research analyst for data entry. However, additional steps involving the removal of demographic identifiers were necessary to protect the confidentiality of patients’ personal health information. In addition, almost immediately it was found that there were inconsistencies in how clinicians were interpreting some of the items that they were asked to complete with the CHIA Part B. Meetings were held and consensus obtained on interpretation of items among providers. However, clarification of items on the instruments, as mentioned above, resulted in the need to request IRB modifications and additional delays in the process.

In addition to the challenge of multiple IRB submissions, there has been a cost to the clinic in terms of time spent on staff and clinician training for the implementation of the tool. Extra staff meetings had to be scheduled to introduce the process to front office staff to ensure consistency and accuracy. In a busy clinic, adding another age-specific form to charts and asking reception staff to copy and track these has the potential to lead to errors. Furthermore, clinicians had to plan time away from patient care duties to complete the CHIA Part B.

Finally, clinic providers did not anticipate the level of assistance that would be needed for some adolescents to complete the CHIA Part A. The tool is completed by the adolescent while alone in the examination room. The provider reviews the form with the teen and in this process, completes the confidential psycho-social assessment that is standard practice (Elster, 1998). It can take a young adolescent (12-14 years) up to 10 minutes to fill out the form, often needing assistance from the provider to explain questions, while older adolescents (15-18) typically need less time and less assistance. While encouraging productive dialogues about adolescent risk behaviors with younger teens, this type of provider involvement in tool completion results in the need for more time to complete adolescent histories and physical exams.

Benefits

Implementation of the CHIA has resulted in both expected and unexpected benefits to the quality of the client visit and to the clinical practice. To the delight of clinic providers, the process of filling out the tool highlights for the patient and family important aspects of their health, and helps prepare them to organize their thoughts and questions before the clinical encounter. Many parents, for example, have asked about appropriate servings of fruits and vegetables for their child, or the recommended amount of television to allow, after having responded to questions about these practices. Review of the completed CHIA allows the clinician to focus on areas needing clinical attention and to target anticipatory guidance. Clinicians have reported that this increased focus streamlines patient visits. While this is only based upon anecdotal reports, the finding lends support for the continued use of the CHIA in a busy clinic environment. Moreover, it has been suggested that gearing specific anticipatory guidance to the identified needs of parents is much more effective than conveying general messages about feeding and safety, for example (Nelson, Wissow, & Cheng, 2003). The written survey also allows the patient or parent the choice of written or verbal disclosure of sensitive information, possibly resulting in increased disclosure (Kemper, 1992).

As a quality control tool, the CHIA also has proven beneficial to the practice. Its continued use ensures that all clients are assessed for all LHI in a standardized fashion annually, constituting a higher level of care. In addition, the chart reviews provide further opportunity for care management and peer review. On several occasions it has been found that a BMI was not calculated or plotted, for example, or a mental health referral or diagnosis of anemia required further follow up.

Finally, as expected, information gathered with the CHIA provides quantitative data on the prevalence of particular health-related problems and practices among the VHS population. Already it is possible to compare some of the clinic’s information with data from the local and state level, and the process of making these comparisons is stimulating new community partnerships. The VHS data will guide clinicians in determining which LHI require new clinic- based interventions. It is hoped that ultimately these combined efforts will further the progress toward Healthy People 2010 goals.

The development and implementation of the CHIA was challenging and rewarding with both expected and unexpected benefits. We learned a number of lessons in the process of developing and implementing this health tool. First, more extensive pilot testing of both parts of the CHIA could have prevented multiple IRB submissions for modifications. Second, implementation of the project requires clinician time away from seeing patients; many items on chart review cannot be accurately or confidentially collected by a research or medical assistant. Third, as an assessment tool, the CHIA Part A does require clinician review and interpretation with the parent or adolescent patient to appropriately interpret responses to particular items. In the end, however, what has most impressed the design committee and clinic providers are the unexpected benefits of using the tool. It has facilitated our asking sensitive questions and initiating important health discussions. We are able to target counseling and anticipatory guidance in a way that greatly improves our efficiency in clinical encounters.

What originally seemed like a potential burden to the administrative and clinical staff and to clinic flow to collect data for a research study turned out to be an asset to patient care. While the benefits to individual patient care are evident, we also anticipate the potentially rich application of the findings in the development of clinic-based interventions.

Table 1. Ten Leading Health Indicators

Physical activity

Overweight

Tobacco use

Substance abuse

Responsible sexual behavior

Mental health

Injury and violence

Environmental health

Immunizations

Access to health care

Note. From U.S. Department of Health and Human Services (2000)

References

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California Health Interview Survey (2001 & 2003). Retrieved October 14, 2005, from http://www.chis.ucla.edu/

California Healthy Kids Survey (2005). Retrieved September 8, 2005 from http://www.wested.org/hks

Centers for Disease Control and Prevention (2004, May 21). Surveillance summaries. [Electronic version]. Morbidity and Morality Weekly Report, 53(SS-2).

Clotfelter, A., Pohl, J.M., & Guthrie, B. (1999). Smoking prevention among children and adolescents: A primary care issue. American Journal of Nursing Practitioners, 3(4), 7-10, 15-8.

DiFranza, J.R., Aligne, C.A., & Weitzman, M. (2004). Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics, 113(4 Suppl.), 1007-1115.

Elster, A.B. (1998). Comparison of recommendations for adolescent clinical preventive services developed by national organizations. Archives of Pediatrics and Adolescent Medicine, 152, 193-198.

Elster, A.B., & Kuznets, N.J. (1994). Guidelines for adolescent preventive services. Baltimore: Williams and Wilkins.

Forrest, C.B., Simpson, L., & Clancy, C. (1997). Child health services research: Challenges and opportunities. Journal of the American Medical Association, 277, 1787-1793.

Haire-Joshu, D., & Nanney, M.S. (2002 May-June). Prevention of overweight and obesity in children: Influences on the food environment. Diabetes Education, 28(3), 415-423.

Hofhuis,W., de Jongste, J.C., & Merkus, P.J. (2003). Adverse health effects of prenatal and postnatal tobacco smoke exposure on children. Archives Disease in Childhood, 88, 1086-1090.

Humphreys, J., Martin, H., Roberts, B., & Ferretti, C. (2004). Strengthening an academic nursing center through partnership. Nursing Outlook, 52, 197-202.

Hymowitz, N., Cummings, K.M., Hyland, A., Lynn, W.R., Pechacek, T.F., & Hartwell, T.D. (1997). Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tobacco Control, 6(Suppl. 2), S57-62.

Kearney, M.H., & O’Sullivan, J. (2003, March). Identity shifts as turning points in health behavior change. Western Journal of Nursing Research, 25(2), 134-152.

Kemper, KJ. (1992, March). Self-administered questionnaire for structured psychosocial screening in pediatrics. Pediatrics, 89(3), 433-436.

McGlynn, E.A., & Halfon, N. (1998). Overview of issues in improving quality of care for children. Health Services Research, 33, 977-1000.

Nelson, C.S., Wissow, L.S., & Cheng, T.L. (2003). Effectiveness of anticipatory guidance: Recent developments. Current Opinion in Pediatrics, 15, 630-635.

Seid, M., Varni, J.W., & Kurtin, P.S. (2000). Measuring quality of care for vulnerable children: Challenges and conceptualization of a pediatric outcome measure of quality. American Journal of Medical Quality, 15(6), 182-188.

Sell, R.L., & Becker, J.B. (2001). Sexual orientation data collection and progress toward Healthy People 2010. American Journal of Public Health, 91(6), 876-882.

Sieving, R.E., Oliphant, J.A., & Blum, R.W. (2002). Adolescent sexual behavior and sexual health. Pediatrics in Review, 23, 407- 415.

Simmons, M., Shalwitz, J., Pollock, S., & Young, A. (2003). Understanding confidentiality and minor consent in California: An adolescent provider toolkit (1st rev. ed.). Adolescent Health Working Group, San Francisco Health Plan. Retrieved on July 13, 2005, from http://ahwg. net/resources/C&C1stRevised+NYCL0204.pdf

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Kristen Sligar, MS, RN, FNP, is Assistant Clinical Professor, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA.

Molly Savitz, MSN, RN, FNP, is Assistant Clinical Professor, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA.

Naomi A. Schapiro, MS, RN, CPNP, is Associate Clinical Professor, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA.

Abbey Alkon, PhD, RN, PNP, is Associate Professor, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA.

Helen Martin, MSN, RN, FNP, is Clinical Director, University of California, San Francisco Valencia Health Services, San Francisco, CA.

Janice Humphreys, PhD, RN, CS, NP, is Associate Professor, Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, CA.

Acknowledgment: UCSF Valencia Health Services thanks the Health Resources and Services Administration for the support provided by the Bureau of Health Professions, Grant #D11HPOO510.

Appendix 1. Child Health Indicator Assessment: Part A – Adolescent Items

1. Do you get active exercise (where you are breathing hard or sweating) for at least 20 minutes, 3 or more times per week?

2. How many hours do you usually watch TV/videos or play computer games each day?

3. How many servings of fruits _____(#) and vegetables _____(#) do you usually eat each day?

4. How often do you spend time in a place where someone smokes?

5. Have you ever smoked?

6. If you smoke, how old were you when you started smoking?

7. If you smoke, how many times have you tried to quit?

8. In the past 30 days, have you ridden in a car with a driver who had been drinking alcohol?

9. Have you ever tried alcohol or drugs?

10. Have you used alcohol or drugs in the past 30 days?

11. Have you had more than 5 drinks at the same time in the past 30 days?

12. During your life, how many times have you taken steroid pills or shots without a doctor’s prescription?

13. During your life, the person(s) you have ever had sexual contact with is (are):

a. I have not had sexual contact with anyone.

b. Females.

c. Males.

d. Males and females.

14. Do you use condoms when you have sex?

15. Have you ever been forced or pressured to have sex?

16. Have you ever had a physical fight with a current or former girlfriend or boyfriend?

17. Have you ever been hit, slapped, kicked, or punched by anyone?

18. Do you feel sad, down, depressed, or angry?

19. Have you ever tried to hurt yourself or kill yourself?

20. When you ride a bike, scooter, or skateboard, do you wear a helmet?

21. Do you spend time in a home where a gun is kept?

22. When you ride in a car, do you wear your seat belt?

23. Does your home have a working smoke detector on every floor?

24. Does your home have adequate heat, electricity, and plumbing?

25. Have you had health insurance every month of the past year?

26. Have you been hospitalized for asthma in the past year?

Copyright Anthony J. Jannetti, Inc. Mar/Apr 2007

(c) 2007 Pediatric Nursing. Provided by ProQuest Information and Learning. All rights Reserved.