Winning with CF 2010: Pre-class Survey #1

These questions are gathering some basic information about your child with CF as well as identifying the areas you might be having trouble with. By the end of this class, you will have new ways to handle many of these issues.

1. In order for us to match up your pre- and post class surveys, we need you to pick a code name. My code name is:

In order for us to match up your pre- and post class surveys, we need you to pick a code name. My code name is:

2. What best describes your child's medical adherence? (check one box for each item)

	All of the time	Most of the time	Some of the time	Not much of the time
Pancreatic Enzymes	What best describes your child's medical adherence? (check one box for each item) Pancreatic Enzymes All of the time	Pancreatic Enzymes Most of the time	Pancreatic Enzymes Some of the time	Pancreatic Enzymes Not much of the time
Nutrition	Nutrition All of the time	Nutrition Most of the time	Nutrition Some of the time	Nutrition Not much of the time
Breathing Treatments	Breathing Treatments All of the time	Breathing Treatments Most of the time	Breathing Treatments Some of the time	Breathing Treatments Not much of the time
Airway Clearance	Airway Clearance All of the time	Airway Clearance Most of the time	Airway Clearance Some of the time	Airway Clearance Not much of the time
Exercise	Exercise All of the time	Exercise Most of the time	Exercise Some of the time	Exercise Not much of the time

Comments

3. What is the most common reason for your child's non- adherence?

	Forgetting	Resistant behavior	Don't see value in it	Financial Issues	Not Enough Time	Embarrassment	Need more training/ education	Tastes Bad	Side Effects
Pancreatic Enzymes	What is the most common reason for your child's non- adherence? Pancreatic Enzymes Forgetting	Pancreatic Enzymes Resistant behavior	Pancreatic Enzymes Don't see value in it	Pancreatic Enzymes Financial Issues	Pancreatic Enzymes Not Enough Time	Pancreatic Enzymes Embarrassment	Pancreatic Enzymes Need more training/ education	Pancreatic Enzymes Tastes Bad	Pancreatic Enzymes Side Effects
Nutrition	Nutrition Forgetting	Nutrition Resistant behavior	Nutrition Don't see value in it	Nutrition Financial Issues	Nutrition Not Enough Time	Nutrition Embarrassment	Nutrition Need more training/ education	Nutrition Tastes Bad	Nutrition Side Effects
Breathing Treatments	Breathing Treatments Forgetting	Breathing Treatments Resistant behavior	Breathing Treatments Don't see value in it	Breathing Treatments Financial Issues	Breathing Treatments Not Enough Time	Breathing Treatments Embarrassment	Breathing Treatments Need more training/ education	Breathing Treatments Tastes Bad	Breathing Treatments Side Effects
Airway Clearance	Airway Clearance Forgetting	Airway Clearance Resistant behavior	Airway Clearance Don't see value in it	Airway Clearance Financial Issues	Airway Clearance Not Enough Time	Airway Clearance Embarrassment	Airway Clearance Need more training/ education	Airway Clearance Tastes Bad	Airway Clearance Side Effects
Exercise	Exercise Forgetting	Exercise Resistant behavior	Exercise Don't see value in it	Exercise Financial Issues	Exercise Not Enough Time	Exercise Embarrassment	Exercise Need more training/ education	Exercise Tastes Bad	Exercise Side Effects

Comments:

4. Please select the best response for each question:

	Strongly Disagree	Disagree	Agree	Strongly Agree
My child complies with medical requirements without my reminding, lecturing or coercion.	Please select the best response for each question: My child complies with medical requirements without my reminding, lecturing or coercion. Strongly Disagree	My child complies with medical requirements without my reminding, lecturing or coercion. Disagree	My child complies with medical requirements without my reminding, lecturing or coercion. Agree	My child complies with medical requirements without my reminding, lecturing or coercion. Strongly Agree
I have the parenting skills I need to handle my child’s behavioral and emotional issues.	I have the parenting skills I need to handle my child’s behavioral and emotional issues. Strongly Disagree	I have the parenting skills I need to handle my child’s behavioral and emotional issues. Disagree	I have the parenting skills I need to handle my child’s behavioral and emotional issues. Agree	I have the parenting skills I need to handle my child’s behavioral and emotional issues. Strongly Agree
I feel supported and understood by others in regards to our family’s healthcare challenges.	I feel supported and understood by others in regards to our family’s healthcare challenges. Strongly Disagree	I feel supported and understood by others in regards to our family’s healthcare challenges. Disagree	I feel supported and understood by others in regards to our family’s healthcare challenges. Agree	I feel supported and understood by others in regards to our family’s healthcare challenges. Strongly Agree
Despite our challenges, I am hopeful about the future. I can handle it!	Despite our challenges, I am hopeful about the future. I can handle it! Strongly Disagree	Despite our challenges, I am hopeful about the future. I can handle it! Disagree	Despite our challenges, I am hopeful about the future. I can handle it! Agree	Despite our challenges, I am hopeful about the future. I can handle it! Strongly Agree

5. Overall, the grade I would give my child on his/her self-care performance is (A,B,C,D,F):

Overall, the grade I would give my child on his/her self-care performance is (A,B,C,D,F):

6. The grade I would give myself on my response to my child’s performance is (A,B,C,D,F):

The grade I would give myself on my response to my child’s performance is (A,B,C,D,F):

7. My child is: ____________ years old.

My child is: ____________ years old.

8. My biggest parenting challenge is:

My biggest parenting challenge is:

9. I hope to learn:

I hope to learn:

Winning with CF 2010: Pre-class Survey #1
Exit this survey

1. About Your Child...

1. In order for us to match up your pre- and post class surveys, we need you to pick a code name. My code name is:

2. What best describes your child's medical adherence? (check one box for each item)

3. What is the most common reason for your child's non- adherence?

4. Please select the best response for each question:

5. Overall, the grade I would give my child on his/her self-care performance is (A,B,C,D,F):

6. The grade I would give myself on my response to my child’s performance is (A,B,C,D,F):

7. My child is: ____________ years old.

8. My biggest parenting challenge is:

9. I hope to learn:

Winning with CF 2010: Pre-class Survey #1Exit this survey

1. About Your Child...

1. In order for us to match up your pre- and post class surveys, we need you to pick a code name. My code name is:

2. What best describes your child's medical adherence? (check one box for each item)

3. What is the most common reason for your child's non- adherence?

4. Please select the best response for each question:

5. Overall, the grade I would give my child on his/her self-care performance is (A,B,C,D,F):

6. The grade I would give myself on my response to my child’s performance is (A,B,C,D,F):

7. My child is: ____________ years old.

8. My biggest parenting challenge is:

9. I hope to learn:

Winning with CF 2010: Pre-class Survey #1
Exit this survey