DePaul Pediatric Health Questionnaire (Child Version)

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Transcription:

DePaul Pediatric Health Questionnaire (Child Version) 1 Date For all of the following questions, please provide or circle only one answer unless otherwise asked. 1. How old are you?.... Are you male or female? Male... 1 Female.... Are you of Latino or Hispanic origin? Yes... 1 No... 4. To which of the following race(s) do you belong? Black, African-American... 1 White... American Indian or Alaska Native... Asian or Pacific Islander... 4 Some other race (Please write-in below).... What grade are you in or what was the last grade that you completed?. Do you attend school or do you have home-schooling/homebound instruction? Attend School...1 OR Home-school/Homebound Instruction (Please write-in below)... When did you start home-schooling/homebound Instruction? 7. How many days of school do you usually miss in one month?

8. Please fill out this chart (go from left to right) Question #8 Have you been experiencing any of the following symptoms / problems within the last month? CIRCLE ONE: Y=YES N=NO If YES, then answer the rest of the questions in the chart If NO, then go to the next symptom on the list. 1) Fatigue/Extreme Y N tiredness ) Feeling worse after Y N doing activities that require physical or mental effort ) Feeling tired after you Y N wake up in the morning 4) Need to nap every day Y N ) Problems falling asleep Y N ) Problems staying Y N asleep 7) Waking up early in the Y N morning (like am) 8) Problems remembering Y N things 9) Difficulty paying Y N attention for a long period of time 10) Difficulty finding the Y N right word to say 11) Difficulty Y N understanding things 1) Only able to focus on Y N one thing at a time 1) Frequently losing your Y N train of thought 14) Slowness of thought Y N 1) Absent-mindedness or forgetfulness Y N Duration: When was the first time that you had this symptom? Month or Season Frequency: How often do you have this symptom? Year 1...Hardly ever 4...Half of the time 7...Always Severity: How much does this symptom bother you? 1 (no problem)... 4 (moderate problem).... 7 (big problem)

#8 continued Have you been experiencing any of the following symptoms / problems within the last month? CIRCLE ONE: Y=YES N=NO If YES, then answer the rest of the questions in the chart If NO, then go to the next symptom on the list. 1) Recent trouble with Y N math or numbers 17) Feel unsteady on your Y N feet, like you might fall 18) Shortness of breath or Y N trouble catching your breath 19) Dizziness Y N 0) Irregular heart beats Y N 1) Losing or gaining Y N weight ) Not wanting to eat Y N ) Sweating hands Y N 4) Night sweats Y N ) Feel chills or shivers Y N ) Feeling hot or cold Y N 7) Feeling like you have Y N a high temperature 8) Feeling that your Y N temperature is low 9) Sore throat Y N 0) Tender/sore lymph Y N nodes 1) Fever and sweats Y N ) Some smells, foods, or Y N chemicals make you feel sick ) Rash(es) Y N Duration: When was the first time that you had this symptom? Month or Season Frequency: How often do you have this symptom? Year 1...Hardly ever 4...Half of the time 7...Always Severity: How much does this symptom bother you? 1 (no problem)... 4 (moderate problem).... 7 (big problem)

#8 continued Have you been experiencing any of the following symptoms / problems within the last month? CIRCLE ONE: Y=YES N=NO If YES, then answer the rest of the questions in the chart If NO, then go to the next symptom on the list. (4) Allergies Y N ) Mood changes Y N ) Anxiety Y N 7) Pain or aching in your Y N muscles 8) Muscle twitches Y N 9) Pain/stiffness/ Y N tenderness in more than one joint without swelling or redness 40) Eye pain Y N 41) Vomiting/ Y N throwing up 4) Nausea/ feeling like Y N you might throw up 4) Chest pain or Y N heartburn 44) Upset stomach Y N 4) Abdomen/stomach Y N pain 4) Ringing in Ears Y N 47) Headaches** Y N Duration: When was the first time that you had this symptom? Month or Season Frequency: How often do you have this symptom? Year 1...Hardly ever 4...Half of the time 7...Always 4 Severity: How much does this symptom bother you? 1 (no problem)... 4 (moderate problem).... 7 (big problem) **IF you have headaches now, do you get them more often, in a different place, or do the headaches feel worse than they did in the past? (You may circle more than one answer.) Headaches happen more often... 1 Headaches feel worse/more severe... Headaches are in a different place/spot...

9. Do you have any medical illness that might be causing your symptoms? No... 1 Yes (What medical illnesses do you have?).. 10. Do you seem to catch illnesses more easily than other people your age? Yes... 11. Does it seem to take longer for you to get better after you are sick than other people your age? Yes... 1. How does being physically active (such as using stairs, walking, playing sports, doing chores, getting dressed) make you feel for the rest of the day? Much more tired than usual... 1 More tired than usual... Has no effect... More energetic than usual... 4 Much more energetic than usual... 1a. Do you participate in any hobbies or activities outside of school? Yes... 1 No... 1b. Are you currently able to carry out your activities or hobbies? Yes... 1 No... IF NO, when and why did you quit your hobbies/activities: 14. Have you been experiencing any problems with fatigue/ extreme tiredness for at least one month? No (Stop here)... 1 Yes (Continue to next page)... IF YES, For about how many months?

1. What do you think the cause of your fatigue or tiredness is? 1. Do you think that your fatigue is caused by ongoing activity? Yes... 1 No... 17. Did your fatigue illness start after you experienced? (Circle one or more.) An infectious illness... 1 An accident... A trip or vacation... An immunization (shot at doctor s office)... 4 Surgery... Severe stress (bad or unhappy event(s))... Other (Please write in below)... 7 18. How long did it take for your problem with fatigue or tiredness to get started? Rapidly - within 4 hours... 1 Over 1 week... Over 1 month... Over - months... 4 Over 7-11 months... Over 1- years... Longer than years... 7 I have always experienced fatigue... 8 19. When you first became sick what were your worst symptoms? a. b. c. 0. Right now, what are your worst symptoms? a. b. c.

1. Do your symptoms change over time? Yes... 7. Do you limit or cut back your activity levels to avoid feeling even more tired? Yes.... If you rest, does all of your fatigue go away, some of it go away, or none of it go away? All of it goes away(go to Question 4a)... 1 Some of it goes away (Go to Question 4a)... None of it goes away (Go to Question )... 4a. How long do you have to rest before your fatigue gets better? 4b. Will your fatigue come back if you stop resting and start doing something? Yes.... How would you describe the way your fatigue illness is changing over time? My fatigue is getting worse... 1 I have good and bad periods... There is no change... My fatigue is getting better... 4 Thank you for filling out the DePaul Health Questionnaire.

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