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Your child's details:
First name
Family name
NHS Number (if known)
Date of birth (dd/mm/yyyy) (must be less than 16 years old)
Gender
Male
Female
Other
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Address
Postcode
GP Practice name
Other GP Practice name
Parent/Carer details:
First name
Family name
Relationship to child
Other Relationship to child
Email
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For Children with Asthma aged 12+
For Children with Asthma aged 4-11
For Children with Asthma aged under 4 years old
A problem was encountered loading the Asthma questionnaire (DoB check).
Does your child have a diagnosis of asthma?
Yes
No
Unsure
The following questions are for your child to answer. Please assist your child to read each question carefully.
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at school or at home?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
During the past 4 weeks, how often have you had shortness of breath?
More than once a day
Once a day
3-6 times a week
1-2 times a week
Not at all
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
4 or more times a week
2-3 nights a week
Once a week
Once or twice
Not at all
During the past 4 weeks, how often have you used your rescue inhaler (usually blue)?
3 or more times a day
1-2 times a day
2-3 times a week
Once a week or less
Not at all
How would you rate your asthma control during the past 4 weeks?
Not controlled
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
The following questions are for you and your child to answer. Please read each question carefully and select the most suitable answer.
Part 1 - for your child to answer (they may need some help)
How is your asthma today?
Very Bad
Bad
Good
Very Good
How much of a problem is your asthma when you run, exercise or play sports?
It's a big problem, I can't do what I want to
It's a problem and I don't like it
It's a little problem but it's okay
It's not a problem
Do you cough because of your asthma?
Yes, all of the time
Yes, most of the time
Yes, some of the time
No, none of the time
Do you wake up at night because of your asthma?
Yes, all of the time
Yes, most of the time
Yes, some of the time
No, none of the time
Part 2 - for you to answer
During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
During the last 4 weeks, how many days did your child wake up during the night because of asthma?
Not at all
1-3 days
4-10 days
11-18 days
19-24 days
Everyday
Please read each question carefully and select the most suitable answer.
In the past 4 weeks, how much of the time did your child's asthma keep them from getting as much done at nursery, school or at home?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
During the past 4 weeks, how often has your child had shortness of breath?
More than once a day
Once a day
3-6 times a week
1-2 times a week
Not at all
During the past 4 weeks, how often did your child's asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake them up at night or earlier than usual in the morning?
4 or more times a week
2-3 nights a week
Once a week
Once or twice
Not at all
During the past 4 weeks, how often has your child used their rescue inhaler (usually blue)?
3 or more times a day
1-2 times a day
2-3 times a week
Once a week or less
Not at all
How would you rate your child's asthma control during the past 4 weeks?
Not controlled
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
For Children with Constipation
Does your child have a diagnosis of constipation?
Yes
No
Unsure
Please select one answer for each of the following questions about your child's symptoms of constipation. You can complete these questions together with your child.
Please use the Bristol Stool Chart to help identify your child's usual stool type.
Type 1 - Separate hard lumps, like nuts (hard to pass)
Type 2 - Sausage-shaped, but lumpy
Type 3 - Sausage-shaped, but with cracks on surface
Type 4 - Sausage or snake like, smooth and soft
Type 5 - Soft blobs with clear-cut edges (easy to pass)
Type 6 - Fluffy pieces with ragged edges, mushy
Type 7 - Watery, no solid pieces (entirely liquid)
During an average week:
How often does your child open their bowels?
≤2 (twice or less)
≥3 (three times or more)
How often does your child pass hard stools? These look like Type 1, 2 or 3 on the Bristol Stool Chart.
At least once
Occasionally
Never
How often does your child feel distress or pain when passing stool?
At least once
Occasionally
Never
How often does your child avoid using the toilet or potty when they need to pass a stool? You might notice your child crossing their legs, sitting on the back of their heels or clenching their buttocks.
At least once
Occasionally
Never
If your child is older, or young and toilet-trained, please answer the following questions. During an average week:
How often does your child soil their underwear?
At least once
Occasionally
Never
Not applicable
How often does your child pass large stools or stools that block the toilet?
At least once
Occasionally
Never
Not applicable
For Children with Eczema
Does your child have a diagnosis of eczema?
Yes
No
Unsure
Please select one response for each of the seven questions below about your child's eczema. You can complete these questions together with your child.
Over the last week, on how many days has your child's skin been itchy because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many nights has your child's sleep been disturbed because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many days has your child's skin been bleeding because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many days has your child's skin been weeping or oozing clear fluid because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many days has your child's skin been cracked because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many days has your child's skin been flaking off because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Over the last week, on how many days has your child's skin felt dry or rough because of their eczema?
No days1-2 days3-4 days5-6 daysEvery day
Strengths and Difficulties Questionnaire
(Please complete only if your child is 4-15 years old)
© Robert Goodman, 2005
For each question, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of the child's behaviour over the last six months.
Not true
Somewhat true
Certainly true
Considerate of other people's feelings
Not trueSomewhat trueCertainly true
Restless, overactive, cannot stay still for long
Not trueSomewhat trueCertainly true
Often complains of headaches, stomach-aches or sickness
Not trueSomewhat trueCertainly true
Shares readily with other children (treats, toys, pencils etc.)
Not trueSomewhat trueCertainly true
Often has temper tantrums or hot tempers
Not trueSomewhat trueCertainly true
Rather solitary, tends to play alone
Not trueSomewhat trueCertainly true
Generally obedient, usually does what adults request
Not trueSomewhat trueCertainly true
Many worries, often seems worried
Not trueSomewhat trueCertainly true
Helpful if someone is hurt, upset or feeling ill
Not trueSomewhat trueCertainly true
Constantly fidgeting or squirming
Not trueSomewhat trueCertainly true
Has at least one good friend
Not trueSomewhat trueCertainly true
Often fights with other children or bullies them
Not trueSomewhat trueCertainly true
Often unhappy, down-hearted or tearful
Not trueSomewhat trueCertainly true
Generally liked by other children
Not trueSomewhat trueCertainly true
Easily distracted, concentration wanders
Not trueSomewhat trueCertainly true
Nervous or clingy in new situations, easily loses confidence
Not trueSomewhat trueCertainly true
Kind to younger children
Not trueSomewhat trueCertainly true
Often lies or cheats
Not trueSomewhat trueCertainly true
Picked on or bullied by other children
Not trueSomewhat trueCertainly true
Often volunteers to help others (parents, teachers, other children)
Not trueSomewhat trueCertainly true
Thinks things out before acting
Not trueSomewhat trueCertainly true
Steals from home, school or elsewhere
Not trueSomewhat trueCertainly true
Gets on better with adults than with other children
Not trueSomewhat trueCertainly true
Many fears, easily scared
Not trueSomewhat trueCertainly true
Sees tasks through to the end, good attention span
Not trueSomewhat trueCertainly true
Strengths and Difficulties Questionnaire
© Robert Goodman, 2005
Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?
No
Yes - minor difficulties
Yes - definite difficulties
Yes - severe difficulties
 
NoYes - minor difficultiesYes - definite difficultiesYes - severe difficulties
Please answer the following questions about these difficulties.
How long have these difficulties been present?
Less than a month
1-5 months
6-12 months
Over a year
 
Less than a month1-5 months6-12 monthsOver a year
Do the difficulties upset or distress your child?
Not at all
Only a little
Quite a lot
A great deal
 
Not at allOnly a littleQuite a lotA great deal
Do the difficulties interfere with your child's everyday life in the following areas?
Not at all
Only a little
Quite a lot
A great deal
HOME LIFE
Not at allOnly a littleQuite a lotA great deal
FRIENDSHIPS
Not at allOnly a littleQuite a lotA great deal
CLASSROOM LEARNING
Not at allOnly a littleQuite a lotA great deal
LEISURE ACTIVITIES
Not at allOnly a littleQuite a lotA great deal
Do the difficulties put a burden on you or the family as a whole?
Not at all
Only a little
Quite a lot
A great deal
Do the difficulties put a burden on you or the family as a whole?
Not at allOnly a littleQuite a lotA great deal
Background Information
Answering these will help us direct you to free community resources that could support you in caring for your family.
Do you have concerns about your housing situation?
Yes
No
Rather not say
Do you always have enough food for your family?
Yes
No
Rather not say
Do you ever struggle to pay your household bills?
Yes
No
Rather not say
Do you have any concerns about your mental wellbeing?
Yes
No
Rather not say
Do you or anyone else in the household smoke?
Yes
No
Rather not say
What is the employment status of the main earner in the household?
Self employed
In paid employment (full or part time)
Unemployed
Retired from paid work altogether
On maternity or paternity leave
Look after family or home
Full-time student/at school
Long term sick or disabled
On a government training scheme
Something else
Rather not say
Please give details:
Please select one box that best describes your child's ethnic group or background.
Please describe your child's ethnicity:
What is the language most commonly spoken in your home?
What is the other language most commonly spoken in your home?
Please check one of the options below to indicate if you are happy for CYPHP to use the email you provided to send you a copy of a Health Support Pack for your child.
Yes - send support pack to the email address provided
No - do not send to the email address provided

Thank you for completing the CYPHP Health Check.