Health Care Physical Examination
Item
1. DURING THE PAST 12 MONTHS, did this child see a doctor, nurse, or other health care professional for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care?
boolean
C0086388 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Item
2. If yes, DURING THE PAST 12 MONTHS, how many times did this child visit a doctor, nurse, or other health care professional to receive a PREVENTIVE check-up?
text
C0086388 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0481566 (UMLS CUI [1,3])
Code List
2. If yes, DURING THE PAST 12 MONTHS, how many times did this child visit a doctor, nurse, or other health care professional to receive a PREVENTIVE check-up?
CL Item
0 visits ➔ SKIP to question C5 (1)
CL Item
2 or more visits (3)
Item
3. Thinking about the LAST TIME you took this child for a preventive check-up, about how long was the doctor or health care provider who examined this child in the room with you? Your best estimate is fine.
text
C0449238 (UMLS CUI [1,1])
C0086388 (UMLS CUI [1,2])
C0582103 (UMLS CUI [1,3])
C0481566 (UMLS CUI [1,4])
Code List
3. Thinking about the LAST TIME you took this child for a preventive check-up, about how long was the doctor or health care provider who examined this child in the room with you? Your best estimate is fine.
CL Item
Less than 10 minutes (1)
CL Item
10-20 minutes (2)
CL Item
More than 20 minutes (3)
Health Care Medical Examination Prophylactic measure
Item
4. At his or her LAST preventive check-up, did this child have a chance to speak with a doctor or other health care provider privately, without you or another adult in the room?
boolean
C0086388 (UMLS CUI [1,1])
C0582103 (UMLS CUI [1,2])
C0481566 (UMLS CUI [1,3])
height
Item
5. What is this child’s CURRENT height?
text
C0005890 (UMLS CUI [1])
weight
Item
6. How much does this child currently weigh?
text
C0005910 (UMLS CUI [1])
Item
7. Are you concerned about this child’s weight?
text
C0005910 (UMLS CUI [1])
Code List
7. Are you concerned about this child’s weight?
CL Item
Yes, it’s too high (1)
CL Item
Yes, it’s too low (2)
CL Item
No, I am not concerned (3)
Health Services; Caregiver
Item
8. Is there a place that this child USUALLY goes when he or she is sick or you or another caregiver needs advice about his or her health?
boolean
C0018747 (UMLS CUI [1])
C0085537 (UMLS CUI [2])
Item
9. If yes, where does this child USUALLY go?
text
C0018747 (UMLS CUI [1])
C0085537 (UMLS CUI [2])
Code List
9. If yes, where does this child USUALLY go?
CL Item
Doctor’s Office (1)
C0031834 (UMLS CUI-1)
CL Item
Hospital Emergency Room (2)
C0562508 (UMLS CUI-1)
CL Item
Hospital Outpatient Department (3)
C0557824 (UMLS CUI-1)
CL Item
Clinic or Health Center (4)
C0475309 (UMLS CUI-1)
CL Item
Retail Store Clinic or “Minute Clinic” (5)
CL Item
School (Nurse’s Office, Athletic Trainer’s Office) (6)
CL Item
Some other place (7)
place physical examination
Item
10. Is there a place that this child USUALLY goes when he or she needs routine preventive care, such as a physical examination or well-child check-up?
boolean
C0442504 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
place Health Services
Item
11. If yes, is this the same place this child goes when he or she is sick?
boolean
C0442504 (UMLS CUI [1,1])
C0018747 (UMLS CUI [1,2])
Vision Tests
Item
12. Has this child EVER had his or her vision tested with pictures, shapes, or letters?
boolean
C0042793 (UMLS CUI [1])
Item
13. If yes, what kind of place or places did this child have his or her vision tested?
text
C0442504 (UMLS CUI [1,1])
C0042793 (UMLS CUI [1,2])
Code List
13. If yes, what kind of place or places did this child have his or her vision tested?
CL Item
Eye doctor or eye specialist (ophthalmologist,optometrist) office (1)
C1704292 (UMLS CUI-1)
CL Item
Pediatrician or other general doctor’s office (2)
C0237433 (UMLS CUI-1)
C0017319 (UMLS CUI-3)
CL Item
Clinic or health center (3)
C0475309 (UMLS CUI-1)
CL Item
School (4)
C0036375 (UMLS CUI-1)
CL Item
Other (5)
C0205394 (UMLS CUI-1)
other
Item
13. Specify other
text
C0205394 (UMLS CUI [1])
Item
14. DURING THE PAST 12 MONTHS, did this child see a dentist or other oral health care provider for any kind of dental or oral health care?
text
C0011441 (UMLS CUI [1])
Code List
14. DURING THE PAST 12 MONTHS, did this child see a dentist or other oral health care provider for any kind of dental or oral health care?
CL Item
Yes, saw a dentist (1)
CL Item
Yes, saw other oral health care provider (2)
CL Item
No ➔ SKIP to question C17 (3)
Item
15. If yes, DURING THE PAST 12 MONTHS, did this child see a dentist or other oral health care provider for preventive dental care, such as check-ups, dental cleanings, dental sealants, or fluoride treatments?
text
C0011441 (UMLS CUI [1])
C0919867 (UMLS CUI [2])
C0204175 (UMLS CUI [3])
Code List
15. If yes, DURING THE PAST 12 MONTHS, did this child see a dentist or other oral health care provider for preventive dental care, such as check-ups, dental cleanings, dental sealants, or fluoride treatments?
CL Item
Yes, 2 or more visits (2)
CL Item
No preventive visits in the past 12 months ➔ C17 (3)
Item
16. If yes, DURING THE PAST 12 MONTHS, what preventive dental services did this child receive?
text
C0199176 (UMLS CUI [1,1])
C0237078 (UMLS CUI [1,2])
Code List
16. If yes, DURING THE PAST 12 MONTHS, what preventive dental services did this child receive?
CL Item
Check-up (1)
C0598836 (UMLS CUI-1)
CL Item
Cleaning (2)
C0919867 (UMLS CUI-1)
CL Item
Instruction on tooth brushing and oral health care (3)
C0086388 (UMLS CUI-1)
C0442027 (UMLS CUI-2)
CL Item
X-Rays (4)
C0850567 (UMLS CUI-1)
CL Item
Fluoride treatment (5)
C0204175 (UMLS CUI-1)
CL Item
Sealant (plastic coatings on back teeth) (6)
C0036490 (UMLS CUI-1)
Item
17. DURING THE PAST 12 MONTHS, has this child received any treatment or counseling from a mental health professional?
text
C0584086 (UMLS CUI [1])
C0184647 (UMLS CUI [2])
Code List
17. DURING THE PAST 12 MONTHS, has this child received any treatment or counseling from a mental health professional?
CL Item
no, but this child needed to see a mental health professional (2)
CL Item
no, this child did not need to see a mental health professional➔ SKIP to question C19 (3)
Item
18. How much of a problem was it to get the mental health treatment or counseling that this child needed?
text
C0584086 (UMLS CUI [1])
C0184647 (UMLS CUI [2])
Code List
18. How much of a problem was it to get the mental health treatment or counseling that this child needed?
CL Item
Small problem (2)
CL Item
Not a problem (3)
medication concentration difficulty behavior difficulty
Item
19. DURING THE PAST 12 MONTHS, has this child taken any medication because of difficulties with his or her emotions, concentration, or behavior?
boolean
C0013227 (UMLS CUI [1,1])
C0235198 (UMLS CUI [1,2])
C0582141 (UMLS CUI [1,3])
Item
20. DURING THE PAST 12 MONTHS, did this child see a specialist other than a mental health professional?
text
C2348234 (UMLS CUI [1])
Code List
20. DURING THE PAST 12 MONTHS, did this child see a specialist other than a mental health professional?
CL Item
No, but this child needed to see a specialist (2)
CL Item
No, this child did not need to see a specialist ➔ SKIP to question C22 (3)
Item
21. How much of a problem was it to get the specialist care that this child needed?
text
C2348234 (UMLS CUI [1])
Code List
21. How much of a problem was it to get the specialist care that this child needed?
CL Item
Small problem (2)
CL Item
Not a problem (3)
Alternative Medicine acupuncture Acupuncture Chiropractic
Item
22. DURING THE PAST 12 MONTHS, did this child use any type of alternative health care or treatment?
boolean
C0002346 (UMLS CUI [1,1])
C0394664 (UMLS CUI [1,2])
C0344217 (UMLS CUI [1,3])
Item
23. DURING THE PAST 12 MONTHS, was there any time when this child needed health care but it was not received?
text
C0086388 (UMLS CUI [1,1])
C0237078 (UMLS CUI [1,2])
C0184643 (UMLS CUI [1,3])
Code List
23. DURING THE PAST 12 MONTHS, was there any time when this child needed health care but it was not received?
CL Item
No ➔ SKIP to question C26 (2)
Medical Care
Item
24. If yes, which types of care were not received? Medical Care?
boolean
C0496675 (UMLS CUI [1])
Dental Care
Item
24. If yes, which types of care were not received? Dental Care?
boolean
C0237078 (UMLS CUI [1])
Vision Care
Item
24. If yes, which types of care were not received? Vision Care?
boolean
C0150177 (UMLS CUI [1])
Hearing Care
Item
24. If yes, which types of care were not received? Hearing Care?
boolean
C0200310 (UMLS CUI [1])
Mental Health Services
Item
24. If yes, which types of care were not received? Mental Health Services?
boolean
C0025355 (UMLS CUI [1])
other
Item
24. If yes, which types of care were not received? Other, specify:
text
C0205394 (UMLS CUI [1])
Health Care receive Not Eligible
Item
25a. Which of the following contributed to this child not receiving needed health services: This child was not eligible for the services?
boolean
C0086388 (UMLS CUI [1,1])
C1514756 (UMLS CUI [1,2])
C1555471 (UMLS CUI [1,3])
Health Services Not available
Item
25b. Which of the following contributed to this child not receiving needed health services: The services this child needed were not available in your area?
boolean
C0018747 (UMLS CUI [1,1])
C0686905 (UMLS CUI [1,2])
Appointment not available
Item
25c. Which of the following contributed to this child not receiving needed health services: There were problems getting an appointment when this child needed one?
boolean
C1688628 (UMLS CUI [1])
Transport unavailable
Item
25d. Which of the following contributed to this child not receiving needed health services: There were problems with getting transportation or child care?
boolean
C2364112 (UMLS CUI [1])
Doctor_s Office Closed
Item
25e. Which of the following contributed to this child not receiving needed health services: The (clinic/doctor’s) office wasn’t open when this child needed care?
boolean
C1547234 (UMLS CUI [1])
Cost aspects
Item
25f. Which of the following contributed to this child not receiving needed health services: There were issues related to cost?
boolean
C0220812 (UMLS CUI [1])
Item
26. DURING THE PAST 12 MONTHS, how often were you frustrated in your efforts to get services for this child?
text
C0016770 (UMLS CUI [1,1])
C0018747 (UMLS CUI [1,2])
Code List
26. DURING THE PAST 12 MONTHS, how often were you frustrated in your efforts to get services for this child?
Item
27. DURING THE PAST 12 MONTHS, how many times did this child visit a hospital emergency room?
text
C3840745 (UMLS CUI [1])
Code List
27. DURING THE PAST 12 MONTHS, how many times did this child visit a hospital emergency room?
CL Item
2 or more visits (3)
Item
28. Has this child EVER had a special education or early intervention plan?
text
C0013649 (UMLS CUI [1])
C1144883 (UMLS CUI [2])
Code List
28. Has this child EVER had a special education or early intervention plan?
CL Item
no, skip to question C31 (2)
age special education; Early intervention
Item
29. If yes, how old was this child at the time of the FIRST plan?
text
C0001779 (UMLS CUI [1,1])
C0013649 (UMLS CUI [1,2])
C1144883 (UMLS CUI [2])
Receive special education; Early intervention
Item
30.Is this child CURRENTLY receiving services under one of these plans?
boolean
C1514756 (UMLS CUI [1,1])
C0013649 (UMLS CUI [1,2])
C1144883 (UMLS CUI [2])
Item
31. Has this child EVER received special services to meet his or her developmental needs such as speech, occupational, or behavioral therapy?
text
C0037831 (UMLS CUI [1])
C0004933 (UMLS CUI [2])
C1318464 (UMLS CUI [3])
Code List
31. Has this child EVER received special services to meet his or her developmental needs such as speech, occupational, or behavioral therapy?
CL Item
No ➔ SKIP to question D1 (2)
age speech therapy; behavioral therapy; occupational therapy
Item
32. If yes, how old was this child when he or she began receiving these special services?
text
C0001779 (UMLS CUI [1,1])
C0037831 (UMLS CUI [1,2])
C0004933 (UMLS CUI [2])
C1318464 (UMLS CUI [3])
Receive speech therapy; behavioral therapy; occupational therapy
Item
33. Is this child CURRENTLY receiving these special services?
boolean
C1514756 (UMLS CUI [1,1])
C0037831 (UMLS CUI [1,2])
C0004933 (UMLS CUI [2])
C1318464 (UMLS CUI [3])