Job
No.18J7 Page
CHILD HEALTH & DIET SURVEY OMB # xxxx-xxxx
The following questions should be answered about your 6-year-old child. Expiration Date: zz/zz/zzzz
The Public Disclosure Burden Statement
can be found in the cover letter
Section A
During the past month, what were your regular childcare arrangements for your 6-year-old? (Please “X” all that apply)
Before After Weekends or
School School Non-School Days
Parent cared for the child
Childcare in my home provided by someone other than a parent
Childcare in someone else’s home
A before- or after-school childcare program at school
Childcare center
Other
What kind of school does your 6-year-old currently attend? (Please “X” all that apply)
Public Home-schooled
Private My 6-year-old does not attend any type of school (Go to Question 7)
What grade is your 6-year-old in?
Preschool or Junior Kindergarten First grade
Kindergarten Second grade
How many days a week is your child in school?
Whole days: 0 days 1 day 2 days 3 days 4 days 5 days
Half days: 0 days 1 day 2 days 3 days 4 days 5 days
During this school year, has a special plan been developed at school to provide your 6-year-old with extra help or support such as a special needs program or an Individualized Education Program (IEP)?
EXPLANATORY NOTE: Some children have difficulty in school because of a health problem, condition, or disability. These children may receive services from a program called Special Education and have a written intervention plan called an Individualized Education Program (IEP).
Yes No Don’t know
During this school year, has your 6-year-old received any of the following services? (Please “X” all that apply)
Speech or language therapy
Occupational therapy or other type of therapy for help with handwriting or other motor skills
Physical therapy
Special instruction or help in one or more school subjects such as reading or math
Special services because of a problem with vision or hearing
Psychological services or counseling because of a problem with emotions, behavior, or socialization
Behavioral
support, such as a behavior management plan
or individual
support in the classroom by an assistant
Special support because of a chronic health condition
Other (please specify) ______________________________________________________
None of these
None 10 or more books
1 or 2 books Don’t know
3 to 9 books
How often do you read aloud to your 6-year-old?
Never At least 3 times a week
Several times a year Everyday
Several times a month Don’t know
Once a week
Yes No Don’t know
Does your 6-year-old get special lessons or belong to any organization that encourages activities such as sports, music, art, dance, drama, etc.?
Yes No Don’t know
How often has a family member taken or arranged to take your 6-year-old to any type of musical or theatrical performance within the past year?
Never About once a month
Once or twice About once a week or more often
Several times
Here is a list of items that describe children. For each item, please “X” how true it has been for your 6 year-old during the past six months. He or she …
Not Somewhat Certainly
True True True
...is considerate of other people's feelings
...is restless, overactive, cannot stay still for long
...often complains of headaches, stomach aches or sickness
...shares toys or treats readily with other children
...often loses temper
…is rather solitary, prefers to play alone
...is generally well behaved, usually does what adults request
...has many worries, or often seems worried
...is helpful if someone is hurt, upset, or feeling ill
...is constantly fidgeting or squirming
...has at least one good friend
...often fights with other children or bullies them
...is often unhappy, depressed, or tearful
...is generally liked by other children
...is easily distracted, concentration wanders
...: is nervous or clingy in new situations
...is kind to younger children
...often lies or cheats
...is picked on or bullied by other children
...often offers to help others (parents, teachers, other children)
...thinks things out before acting
...steals from home, school or elsewhere
...gets along better with adults than with other children
...has many fears, is easily scared
...has good attention span, sees chores or homework through to the end
Section B
How tall is your 6-year-old now (without shoes)? Please use the enclosed tape measure to measure the height. Have your child back up to a wall with the back of the head, shoulder blades, buttocks, and heels touching the wall. Lay a hard-backed book or other flat item from your child’s head to the wall and level with the floor. Mark the wall under the book and then measure from the floor to the mark. Please tell us the height to the nearest quarter inch.
_____ inches
How much does your 6-year-old weigh now (without shoes)? Please weigh your child on a scale. _____ pounds
How tall was your 6-year-old the last time he or she was measured at a doctor’s visit? ______feet _____ inches
What was the date of the height measurement? Month____ / Day_____ / Year________
How much did your 6-year-old weigh the last time he or she was weighed at a doctor’s visit? _____pounds
What was the date of the weight measurement? Month____ / Day_____ / Year________
Please indicate how you would classify your 6-year-old’s weight at each of the 2 periods listed below:
Very Very
Underweight Underweight Average Overweight Overweight
Now
First year of life
Thinking about your 6-year-old, would you like him or her to weigh:
A lot less A little more
A little less A lot more
About the same
How old was your 6-year-old the first time you took him or her to a dentist?
_____years My 6-year-old has never been to a dentist (Go to Question 12)
During the past 12 months, has your 6-year-old been to a dentist?
Yes No
How many dental cavities (teeth with decay) has your 6-year-old had in his or her lifetime?
None 1 2 3 4 5 6 or more
How often does your 6-year-old usually brush his or her teeth? If someone else brushes your 6-year-old’s teeth, please count this.
Never (Go to Question 14) 2 times a day
A few times a week 3 or more times a day
Once a day
Does
your 6-year-old usually brush his or her teeth by himself or
herself, or does an older child or adult help?
(Please
“X” all that apply)
My 6-year-old brushes his or her teeth by himself or herself
An older child helps my 6-year-old brush his or her teeth
An adult helps my 6-year-old brush his or her teeth
An adult brushes my 6-year-old’s teeth
During the past 12 months, how many times did you take your 6-year-old to a doctor or other health professional for each of the following reasons?
2 3 4 5 6 or
None Once times times times times more times
Routine well child visit
Sick visit
Follow up visit
Emergency room visit due to illness
During the past 12 months, how many times did your 6-year-old have the following infections?
2 3 4 5 6 or
None Once times times times times more times
Ear infection
Sinus infection
Throat infection, e.g. strep throat
Pneumonia or lung infection
Urinary tract infection
Cold or upper respiratory infection
During this current school year, how many days has your 6-year-old missed school because of illness? Count part of the day as a whole day.
None Three to four weeks
1 to 2 days More than one month
3 to 4 days Most of the year
One to two weeks Does not go to school
Does your 6-year-old have any trouble seeing?
No
Yes, but he or she sees normally when wearing eyeglasses
Yes, and eyeglasses cannot correct his or her vision problem enough for him or her to see normally
During the past month, was your 6-year-old given any herbal or botanical remedies or supplements? (Only count things taken by mouth. Do not count anything applied to the skin on administered in any other way.)
Yes No (Go To Question 21a)
Please list all the kinds of herbal or botanical remedies or supplements your 6-year-old was given in the past month.
________________________________________________________________________________________
Why was your 6-year-old given an herbal or botanical remedy or supplement in the past month? (Please X” All That Apply)
To relieve or reduce symptoms of an illness To reduce stress or anxiety
To reduce congestion To help my 6-year-old sleep
To strengthen or maintain health Other: specify__________________________
21A. Has
a doctor or other health professional ever told you that |
|
|
If you answer “Yes” to the first column (21A), please also answer columns 21B and 21C.
|
21B. How old was your 6‑year‑old when you were first told he or she had the condition? (write in 0 if less than 1 year) |
21C. Does your 6‑year‑old currently have the condition? |
Hearing problems Yes No Unsure ______ Years Yes No Unsure
A
digestive problem like colitis,
acid reflux, colic, or
Crohn’s Yes No
Unsure
______
Years Yes No
Unsure
Eczema
or any kind of skin
allergy (e.g., contact dermatitis) Yes
No
Unsure
______
Years Yes No
Unsure
Hay
fever or respiratory allergy
(to pets, pollens, mold,
dust mites, etc.) Yes No
Unsure
______
Years Yes No
Unsure
Drug allergy Yes No Unsure ______ Years Yes No Unsure
Diabetes Yes No Unsure ______ Years Yes No Unsure
Attention
Deficit Disorder or
Attention Deficit Hyperactivity
Disorder, ADD, or ADHD Yes No
Unsure
______
Years Yes No
Unsure
Autism or developmental delay Yes No Unsure ______ Years Yes No Unsure
Depression or anxiety Yes No Unsure ______ Years Yes No Unsure
Celiac disease Yes No Unsure ______ Years Yes No Unsure
Has your 6-year-old ever visited an emergency room or urgent care center because of breathing difficulties?
Yes No Not sure
In the past 12 months, has your 6-year-old used an inhaler or nebulizer?
Yes No (Go To Question 25) Not sure (Go To Question 25)
What are the triggers of your 6-year-old’s breathing difficulties? (Please “X” All That Apply)
Exercise Change of seasons
Drug allergy Cold weather
Infections Humid or hot weather
Inhaled allergens (dust, pet, food, etc) Anger or emotion
Perfume, scented candles, air freshener, etc Other
Tobacco or other smoke Don’t know or not sure
Yes No (Go To Question 27) Not sure (Go To Question 27)
Does your 6-year-old take daily medications either year-round or seasonally to manage his or her asthma?
Yes, year-round Yes, seasonally No
Yes No (Go To Question 30)
If
your 6-year-old was tested by a doctor for a food allergy, what
method was used?
(Please
“X” All That Apply)
Description of symptoms only (no medical testing) Food elimination (withdrawal of the specific food
A skin test to see if symptoms disappeared)
A blood test Food challenge (introduction of a specific food to
An esophageal or intestinal study see if symptoms reappeared)
Yes No
Do you currently avoid any foods or food ingredients for your 6-year-old because of a known or suspected food allergy or intolerance?
Yes No (Go to Section C)
Which foods or food ingredients do you currently avoid for your 6-year-old? (Please “X” All That Apply)
Cow's milk or other dairy products Other seafood (for example clams, mussels, squid)
Soy milk or other soy food Beef, pork, chicken, or other animal meat
Eggs or egg products Wheat or gluten
Peanuts, peanut butter, or peanut oil Non-gluten grain or cereal (for example, oats, buckwheat)
Almonds, pecans, walnuts, or other tree nuts Fruit or fruit juice
Sesame or sesame seed oil Artificial colors or flavors
Mustard, sunflower, or other seeds Sulfites
Fish (for example, salmon, codfish, tuna) None of these
Crustacean shellfish (for example, Other
shrimp, crab, or lobster) (please specify)______________________________
How old was your 6-year-old the first time he or she had an allergic or intolerance reaction to any food?
Less than 1 year 3 to 4 years Not sure
1 to 2 years 5 years or older
Did your 6-year-old have a reaction the first time he or she ate the food?
Yes No Not sure
Did the first reaction to food result in an emergency care visit (urgent care or emergency department)?
Yes No Not sure
Which
of the following symptoms has your 6-year-old had because of a
reaction to food?
(Please
“X” All That Apply)
Congestion or runny nose Vomiting or spitting up
Asthma, wheezing, or trouble breathing Abdominal pain, gassiness, or diarrhea
Irritability or behavior changes Constipation
Swollen eyes or lips Unexplained weight loss or gain
Hives, welts, or flushed and itchy skin Blood in stool
Eczema or persistent skin rash Loss of consciousness or shock
Esophagitis or severe acid reflux None of these
Has your 6-year-old ever been prescribed an Epi-pen or epinephrine autoinjector for management of his or her food allergy?
Yes No
Have you stopped taking your 6-year-old to restaurants, social gatherings, or parties for fear of accidental reactions?
Yes, always Yes, sometimes No
Section C
In a typical week, how many days do you or another adult in your household do any physical activities with your 6-year-old, including things like active games, sports, walks, biking, ice skating, swimming, or other physical activities? Please include only activities where both the adult and your 6-year-old are active.
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
In a typical week, how many days is your 6-year-old physically active for a total of at least 60 minutes per day? Add up all the time your 6-year-old spends in any kind of physical activity that makes him or her sweat or breathe hard (for example, playing tag, running, biking, jumping rope, swimming). If your child is active during recess, please include recess time.
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
Compared with other children of the same age and sex, is your 6-year-old:
A lot more physically active than most A little less physically active than most
A little more physically active than most A lot less physically active than most
Average – same as most Don’t know or not sure
On average, about how many hours per day does your 6-year-old play video games and watch TV programs or videos? (Do not Count School Or Homework Time.)
Weekdays: _______hours -AND- ______minutes -OR- None
Weekends: _______hours -AND- ______minutes -OR - None
Over the past month, how many hours did your 6-year-old usually sleep each night on weekdays? _____ hours
Over the past month, how often has it been difficult to wake up your 6-year-old in the mornings on week days?
Less than once a week 1-2 times per week 3-5 times per week
Less Than Once 1-2 Times 3-5 Times 6-7 Times
A Week Per Week Per Week Per Week
Over
the past month, how often has your 6-year-old
slept about
the same number of hours each night?
Over
the past month, how often has your 6-year old had trouble
falling asleep after going to bed?
Over
the past month, how often has your 6-year-old
woken up
during the night?
Section D
Do you own a pet or does your 6-year-old regularly spend time indoors where a pet lives (such as at day care or in the school classroom)? (Please “X” All That Apply)
No Yes, one or more hamsters, gerbils, or similar pets
Yes, one or more dogs Yes, one or more birds
Yes, one or more cats Yes, other pet
In the last 12 months, how often have the following products been used in your home?
Less than About A Few
Not Once 1-3 times once times Every
at all a month a month a week a week day
Air fresheners including spray, stick, aerosol, or plug-in
Scented candles (burned) or scented oil (burned)
Pesticides (ant or flying insect killer, flea control, other)
How many times a day does your 6-year-old usually eat? Please count all meals and snacks. ____
How many days a week does your 6-year-old usually eat breakfast? (Please “X” Only One Box)
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
How many days a week does your 6-year-old usually eat dinner at home with you or another adult in your household?
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
How many days a week does your 6-year-old usually eat dinner from a fast food restaurant like McDonald’s, Taco Bell, Pizza Hut, etc., including take-out?
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
During the school week, how many days a week does your 6-year-old usually eat lunch at school from each of the following places?
Food brought from home ____
A complete school lunch from the school cafeteria ____
Individual items from the school cafeteria ____
Salad bar in the school cafeteria ____
Fast food from the school cafeteria (such as McDonalds, Taco Bell, or KFC) ____
Food from a school vending machine, school canteen, or school store ____
Does not go to school
During the past month, what type of fat did you most often use to cook with at home? (Please “X” Only One Box)
Butter Olive oil
Margarine Other vegetable oil
Crisco Lard or other animal fat
Corn oil Cooking spray (specify type of oil)______
Canola oil Didn’t use fat in cooking
During the past month, what kind of milk did your 6-year-old usually drink? (Please “X” Only One Box)
Plain Cow’s Milk: Other Milk:
Whole or regular milk Sweetened cow’s milk
2% fat or reduced-fat (chocolate, vanilla, fruit flavored, etc.)
1%, ½%, or low-fat Soy milk
Fat-free, skim, or nonfat Other kind of milk
Didn’t drink milk
During the past month, what type of rice did your 6-year-old eat? (Please “X” Only One Box)
Only white rice Mostly brown rice
Only brown rice About half and half
Mostly white rice Didn’t eat rice
During the past month, what type of pasta did your 6-year-old eat? (Please “X” Only One Box)
Only white pasta Mostly whole wheat pasta
Only whole wheat pasta About half and half
Mostly white pasta Didn’t eat pasta
During the past month, what type of bread did your 6-year-old eat? (Please “X” Only One Box)
Only white bread Mostly whole wheat bread
Only whole wheat bread About half and half
Mostly white bread Didn’t eat bread
During the past month, how often did your 6-year-old eat or drink each food listed below?
Think about all the meals and snacks your 6-year-old had at home, school, restaurants, play dates, and anywhere else. Please include food eaten on weekdays and over the weekend.
If your 6-year-old ate the food once a day or more, write the number per day in the first column. If your 6-year-old ate the food less than once a day, write the number per week in the second column. If your 6-year-old ate the food less than once a week, write the number per month in the third column. If your 6-year-old did not eat the food at all during the past month, check the box in the fourth column. (Fill In Only One Column For Each Item)
Per Per Per Did
Day Week Month not eat
Hot or cold cereals ____ ____ ____
Milk: all types to drink or on cereal ____ ____ ____
Cheese:
all types (include cheese as a snack, on a sandwich,
and in
foods such as lasagna, quesadillas, or casseroles).
Do not
count cheese on pizza ____ ____ ____
Ice
cream or other frozen dairy desserts, such as frozen yogurt
and sherbet. Don’t include sugar free kinds ____ ____ ____
Other
dairy products, such as pudding or yogurt.
Don’t
include sugar free or plain kinds ____ ____ ____
Sugar
free frozen dairy desserts or sugar free pudding, plain or
sugar free yogurt, or other sugar free dairy
products ____ ____ ____
Regular
soda or pop that contains sugar. Don’t include
diet
soda or diet pop ____ ____ ____
Water: include tap, bottled, and unflavored sparkling water ____ ____ ____
100% pure fruit juice or 100% pure vegetable juice ____ ____ ____
Sweetened
drinks: Kool-aid, lemonade, sweet tea, Hi-C,
cranberry
cocktail, Gatorade, etc. ____ ____ ____
Fruits: fresh, frozen, or canned. Don’t include juice ____ ____ ____
Green leafy or lettuce salad, with or without other vegetables ____ ____ ____
Fried potatoes including French fries, home fries and hash browns ____ ____ ____
Other
kinds of potatoes such as baked, boiled, mashed,
sweet
potatoes and potato salad ____ ____ ____
Refried
beans, baked beans, beans in soup, pork and beans,
or any
other cooked dried beans. Don’t include green
beans ____ ____ ____
Other
vegetables: fresh, frozen, or canned (other than lettuce
salads, potatoes, or cooked dried beans) ____ ____ ____
Rice ____ ____ ____
Pasta ____ ____ ____
Pizza:
frozen pizza, fast food pizza, homemade pizza,
or other
pizza ____ ____ ____
Tomato
sauces: Mexican-type salsa made with tomato,
with spaghetti
or noodles or mixed into foods such as lasagna ____ ____ ____
Processed meat: bacon, ham, lunch meats, hot dogs, etc ____ ____ ____
Meat (not processed): chicken, turkey, pork, beef, or lamb ____ ____ ____
Fish or shellfish ____ ____ ____
Peanut butter or peanuts. ____ ____ ____
Bread:
toast, rolls, bagels, cornbread, tortillas, in sandwiches,
pancakes, waffles, etc ____ ____ ____
Sweet
foods: candy, cookies, cake, doughnuts, muffins,
pop-tarts,
etc. Don’t count frozen or sugar free
desserts ____ ____ ____
Popcorn ____ ____ ____
Snacks such as potato chips, corn chips, pretzels, and crackers ____ ____ ____
Please “X” one response for each question which best corresponds to your answer:
Never Rarely Sometimes Often Always
How
often are there fruits or vegetables to snack
on in your
home, such as apples, raisins, carrots,
celery, bananas, or
melon?
How
often do you encourage your 6-year-old
to eat all of the
food on his or her plate?
How
often does your 6-year-old eat all
of the food on his or her
plate?
Please “X” one response for each question which best corresponds to your answer for your 6-year-old child:
Slightly Neither Disagree Slightly
Disagree Disagree Nor Agree Agree Agree
I
make sure that my child does not eat too
many sweets or junk
foods
If
I did not guide or regulate my child’s eating,
he or
she would eat too much of his or her
favorite foods
I
am especially careful to make sure my child
eats enough
My
child will lose appetite for dinner if he or she
has had a
snack just before
My child is always asking for food
If allowed to, my child would eat too much
My child looks forward to mealtimes
My child enjoys a wide variety of foods
Section E
As best you know, which of the following health conditions do you yourself or your 6-year-old’s other relatives have? (Please “X” All That Apply)
Your 6-Year-Old’s Relatives None
You, Brother Grand-Parent, of These
Mother Father or Sister Aunt, or Uncle Relatives
Type 1 diabetes
Adult onset diabetes (Type II)
Asthma
Eczema
or any kind of skin allergy
(e.g., contact dermatitis)
Food allergy
Hay
fever or respiratory allergy (to pets, pollens,
mold, dust
mites, etc)
Overweight or obese
Attention
Deficit Disorder or Attention Deficit
Hyperactivity
Disorder, ADD, or ADHD
Bipolar disorder
Depression other than bipolar disorder
Anxiety
disorder such as generalized
anxiety disorder
Breast cancer
How much do you weigh? ____ pounds
How tall are you? ____ feet ____ inches
What is your age? ____ years
How often do you yourself do vigorous activities for at least 10 minutes that cause heavy sweating or large increases in breathing or heart rate?
____times per day -OR- ____times per week -OR- ___times per month -OR- Less than once a month….
How much time do you usually spend doing these vigorous activities in one session?
____minutes per session -OR- ____hours per session -OR- None….
How often do you do light or moderate activities for at least 10 minutes that cause only light sweating or slight to moderate increase in breathing or heart rate?
____times per day -OR- ____times per week -OR- ___times per month Less than once a month
How much time do you usually spend doing these light or moderate activities in one session?
____minutes per session -OR- ____hours per session None
For each of the following statements, please “X” the box that best describes how often you felt or behaved this way during the past week
Rarely Some or Occasionally
or None of a Little of or a Moderate Most or All
the Time (Less the Time Amount of the of the Time
than 1 day) (1-2 days) Time (3-4 days) (5-7 days)
I was bothered by things that usually don’t bother me.
I had trouble keeping my mind on what I was doing
I felt depressed
I felt that everything I did was an effort
I felt hopeful about the future
I felt fearful
My sleep was restless
I was happy
I felt lonely
I could not get “going”
On average, how many cigarettes do you currently smoke per day? (Write in 0 if you do not smoke)
_____ cigarettes per day
How many people not including yourself smoke inside your home most days? (Include family members, friends, and anyone else.)
0 1 2 3 4 or more
Since the birth of your 6-year-old, have you had any pregnancies that ended in a miscarriage, abortion, or stillbirth?
If so, how many? ____ (Write in 0 if none)
Are you pregnant now?
Yes No
How many children have you had after your 6-year-old?
____children No other children after my 6-year-old (Go To Question 16)
Please answer all columns for each child born after your 6-year-old.
How old was this child
when you completely Did this child ever
Sex Date of birth stopped breastfeeding him or her? participate in WIC?
Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No
Never breastfed
Still breastfed
Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No
Never breastfed
Still breastfed
Boy Girl Month___ / Year___ Breastfed ___ Weeks -OR- ___Months Yes No
Never breastfed
Still breastfed
I stopped breastfeeding and pumping milk for him or her
___Weeks -OR- ___Months Never breastfed or pumped milk
He or she stopped being fed breast milk, including pumped breast milk
___Weeks -OR- ___Months Never fed breast milk
He
or she stopped drinking from a bottle (include breast milk, formula,
juice, water,
and anything else)
___Weeks -OR- ___Months Never drank from a bottle
When you were pregnant with your 6-year-old, did you have gestational diabetes?
Yes No Not sure
Have you worked at a paid job or a business since your 6-year-old was born?
Yes (Go To Question 20) No
For
which of the following reasons have you not worked as a paid
employee since your 6-year-old was born?
(Please
X” All
That Apply)
I wanted to remain at home to raise child/children I had medical complications related to pregnancy
I could not make suitable child care arrangements Other
I could not find a suitable job
(If You Answered Question 19, Go To Question 23)
____Weeks -OR- ____Months -OR- ___Years
Upon returning to work, did you return to a job with the employer you last worked for while pregnant with your 6-year-old?
Yes (Go To Question 23) No
Employer did not make a job available I moved out of the area
Employer was no longer in business Other
I chose not to return to this employer
Yes No (Go To Question 26)
1-9 hours per week 30-34 hours per week
10-19 hours per week 35-40 hours per week
20-29 hours per week More than 40 hours per week
Less than half About half More than half
Does your 6-year-old have any type of health insurance, or is your 6-year-old covered by any kind of private or governmental health or hospitalization plans or health maintenance organization (HMO) plans?
Yes private health insurance or plan or private HMO
Yes,
government plan (Medicaid, State Children’s Health
Insurance Plan (SCHIP), other)
No
During the last 12 months, did you or anyone in your household receive SNAP (Supplemental Nutrition Assistance Program) or Food Stamp benefits?
Yes No
thank you for your help
| File Type | application/msword |
| File Title | Supporting Statement for OMB Review |
| Author | FDA |
| Last Modified By | DPresley |
| File Modified | 2011-07-14 |
| File Created | 2011-07-14 |