Young person's health questionnaire (ages 4-13)

Name *

Date of birth *

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034

Are you a...

Boy Girl Neither a boy or a girl I prefer not to answer I prefer to self-describe

If you chose to self-describe, please answer the next question

I describe myself as...

Ethnicity

• White - English, Welsh, Scottish, Northern Irish or British • White - Irish • White - Gypsy or Irish Traveller • White - Any other White background • Mixed or Multiple ethnic groups - White and Black Caribbean • Mixed or Multiple ethnic groups - White and Black African • Mixed or Multiple ethnic groups - White and Asian • Mixed or Multiple ethnic groups - Any other Mixed or Multiple ethnic background • Asian or Asian British - Indian • Asian or Asian British - Pakistani • Asian or Asian British - Bangladeshi • Asian or Asian British - Chinese • Asian or Asian British - Any other Asian background • Black, African, Caribbean or Black British - African • Black, African, Caribbean or Black British - Caribbean • Black, African, Caribbean or Black British - Any other Black, African or Caribbean background • Any other ethnic group

Religon

No religion Christianity Islam Hinduism Sikhism Judaism Buddhism Other

On a scale of 1 to 10 how healthy are you feeling?

1 (unhealthy) 2 3 4 5 (sort of healthy) 6 7 8 9 10 (very healthy)

Why have you given yourself that score?

Do you think there is anything you could do to make yourself healthier?

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Food

Which foods do you like and not like

What do you eat for breakfast?

Which fruit and vegetables do you like to eat?

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Sport and activities

What sports or activities do you enjoy?

Which clubs do you go to?

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Sleep

Do you sleep OK?

What time do you go to bed?

1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

What time do you wake up?

1 2 3 4 5 6 7 8 9 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

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Health

Have you been to the doctor in the last year?

Yes No

If yes, what for?

Have you had any accidents in the last year?

Yes No

If yes, what for?

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My worry box

Do you worry about anything?

My happy box

Tell us what makes you happy

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Questionnaires for Dorset Council