ALL School-Based Health Center (SBHC) students are taking part in this survey. This survey will help the SBHC understand the concerns that you have about your health. It will help to improve instruction, academic programs and health care programs throughout SBHC.

THIS IS NOT A TEST—there are no right or wrong answers. We are interested in your honest opinions about your health. Filling out this questionnaire is VOLUNTARY. You do not have to answer any question unless you want to. It will be very helpful if you answer as many questions as you can. All of your answers are ANONYMOUS and will be kept CONFIDENTIAL: no one will know that you filled out this survey, and no one will know the answers you give.

THANK YOU FOR YOUR PARTICIPATION

St. John Providence Health System
School-Based Health Centers

Are you

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* 1. Are you

How old are you?

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* 2. How old are you?

What grade are you in?

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* 3. What grade are you in?

What race are you?

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* 4. What race are you?

Who do you live with?

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* 5. Who do you live with?

Altogether, how many people live in your home? (be sure to include yourself)

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* 6. Altogether, how many people live in your home? (be sure to include yourself)

How do you feel most of the time?

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* 7. How do you feel most of the time?

Have you ever been seen by the dentist?

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* 8. Have you ever been seen by the dentist?

Do you brush your teeth every day?

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* 9. Do you brush your teeth every day?

Have you ever been to the doctor?

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* 10. Have you ever been to the doctor?

Are you taking any medicine given by a doctor or nurse?

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* 11. Are you taking any medicine given by a doctor or nurse?

Have you had a headache in the past week (7 days)?

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* 12. Have you had a headache in the past week (7 days)?

Have you had a stomach ache in the past week (7 days)?

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* 13. Have you had a stomach ache in the past week (7 days)?

Does anyone in your household smoke cigarettes?

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* 14. Does anyone in your household smoke cigarettes?

Does anyone in your household drink alcohol?

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* 15. Does anyone in your household drink alcohol?

Does anyone in your household use drugs?

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* 16. Does anyone in your household use drugs?

Do you eat breakfast on school days?

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* 17. Do you eat breakfast on school days?

Do you drink milk every day or have it on cereal?

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* 18. Do you drink milk every day or have it on cereal?

Do you eat fruit every day?

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* 19. Do you eat fruit every day?

Do you eat vegetables every day?

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* 20. Do you eat vegetables every day?

Do you eat or drink any of the following every day

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* 21. Do you eat or drink any of the following every day

What do you USUALLY do most days after school?

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* 22. What do you USUALLY do most days after school?

Do you have a hard time going to sleep at night?

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* 23. Do you have a hard time going to sleep at night?

Do you have trouble staying asleep at night?

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* 24. Do you have trouble staying asleep at night?

Do you wake up in the middle of the night?

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* 25. Do you wake up in the middle of the night?

Do you fall asleep in school sometimes?

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* 26. Do you fall asleep in school sometimes?

Do you get sent to the office for fighting?

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* 27. Do you get sent to the office for fighting?

Do you put your seat belt on when you get into a car?

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* 28. Do you put your seat belt on when you get into a car?

Do you wear a helmet when riding a bike?

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* 29. Do you wear a helmet when riding a bike?

Do you wear a helmet when riding a skateboard or rollerblades?

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* 30. Do you wear a helmet when riding a skateboard or rollerblades?

Do you like school?

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* 31. Do you like school?

Do you get mad a lot?

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* 32. Do you get mad a lot?

When you get mad, what do you do

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* 33. When you get mad, what do you do

Do you have friends?

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* 34. Do you have friends?

Do others kids bully (pick on) you at school?

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* 35. Do others kids bully (pick on) you at school?

Do you like yourself?

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* 36. Do you like yourself?

Do you worry about someone in your home who drinks alcohol or uses drugs?

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* 37. Do you worry about someone in your home who drinks alcohol or uses drugs?

Does anyone touch your private parts (on your body)?

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* 38. Does anyone touch your private parts (on your body)?

Does anyone hurt your body really bad?

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* 39. Does anyone hurt your body really bad?

What makes you scared (afraid)?

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* 40. What makes you scared (afraid)?

Who do you talk to when things bother you?

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* 41. Who do you talk to when things bother you?

When would you want to see the school nurse for doctor?

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* 42. When would you want to see the school nurse for doctor?

Have you ever been told that you have asthma?

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* 43. Have you ever been told that you have asthma?

Does your asthma still bother you?

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* 44. Does your asthma still bother you?

Thank You for Your Participation

St. John Providence School-Based Health Center’s 2014 Elementary Youth Risk Behavior Survey

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