Health Risk Behavior Survey (middle school)

Longitudinal follow-up of Youth with Attention-Deficit/Hyperactivity Disorder identified in Community Settings: Examining Health Status, Correlates, and Effects associated with treatment for ADHD

Attachment B24 Child Health Risk Behaviors (high school) reduced

Attachment B24. Health Risk Behavior Survey (middle school) (Child)

OMB: 0920-0747

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Health Risk Behavior Survey


HEALTH AND HEALTH RISK BEHAVIOR QUESTIONNAIRE: CHILD

High School Version


TABLE OF CONTENTS


  1. Injury 1

  2. Rule Breaking 3

  3. Tobacco/Alcohol/Drug Use 4

  4. Physical Activity 8

  5. Eating 10

  6. Sleep Behavior 10

  7. School Performance 10

  8. Communication 11


I. Injury

The next questions ask about serious injuries that you had in the past year. We want to know about serious injuries that stopped you from doing things like playing, or that made you need to see a doctor, like a broken bone or a cut that required stitches.



  1. How many times were you injured in the past 12 months?

____________________________


  1. In the past twelve months, have you had any of the following injuries? (Check all that apply).


2A. An injury related to playing or having fun (for example, while playing on a bicycle or skateboard)?

  • Yes

  • No



2B. A burn or scald?

  • Yes

  • No



2C. A broken bone?

  • Yes

  • No



2D. An animal bite?

  • Yes

  • No


Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (??).





2E. A poison related injury?

  • Yes

  • No



2F. A cut or pierce that required stitches?

  • Yes

  • No



2G. An injury caused by something like a tool or machine?

  • Yes

  • No


3. How often do you wear a seatbelt when riding in a car?

  • Never

  • Rarely

  • Sometimes

  • Most of the time

  • Always


4. How often do you cross the street or run out into the street without checking for cars?

  • Never

  • Rarely

  • Sometimes

  • Most of the time

  • Always


5. How often do you do dangerous things like jumping off high places?

  • Never

  • Rarely

  • Sometimes

  • Most of the time

  • Always


6. When you ride a bicycle, how often do you wear a helmet?

  • I do not ride a bicycle

  • Never

  • Rarely

  • Sometimes

  • Most of the time

  • Always



7. When you roller blade or ride a skateboard, how often do you wear protective gear such as a helmet, wrist guards, or knee pads?

  • I do not roller blade or ride a skateboard

  • Never

  • Rarely

  • Sometimes

  • Most of the time

  • Always



8. In the past 12 months, have you carried a weapon, such as a gun, knife, or club on school property?

  • Yes

  • No


9. During the past 12 months, how many times were you in a physical fight?

  • 0 times

  • 1 time

  • 2-3 times

  • 4-5 times

  • 6-7 times

  • 8-9 times

  • 10-11 times

  • 12 or more times







10. During the past 12 months, how many times were you in a physical fight in which you were hurt and had to be treated by a doctor?

  • 0 times

  • 1 time

  • 2 – 3 times

  • 4-5 times

  • 6 or more times



11. During the past 12 months, how many times were you in a physical fight on school property?

  • 0 times

  • 1 time

  • 2-3 times

  • 4-5 times

  • 6-7 times

  • 8-9 times

  • 10-11 times

  • 12 or more times


12. Have you ever tried to intentionally hurt yourself?

  • Yes

  • No



II. Rule Breaking

These next few questions are very sensitive and ask about breaking rules and laws. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer.

13. When was the last time you stole something worth more than $50?

  • Within the past month

  • Between 1 month and 6 months ago

  • Between 6 months and 1 year ago

  • Over 1 year ago

  • Never



14. When was the last time you were required to appear in court for something you had done?

  • Within the past month

  • Between 1 month and 6 months ago

  • Between 6 months and 1 year ago

  • Over 1 year ago

  • Never


15. When was the last time you were sent to the principal or counselor for disciplinary reasons?



  • Within the past month

  • Between 1 month and 6 months ago

  • Between 6 months and 1 year ago

  • Over 1 year ago

  • Never


16. When was the last time you were fired from a job?

  • Within the past month

  • Between 1 month and 6 months

  • Between 6 months and 1 year

  • Over 1 year ago

  • Never


17. If you take medication for ADHD (attention deficit/hyperactivity disorder), do you mostly take it yourself without supervision?

  • Yes

  • No

  • I do not take medication for ADHD




18. If you take medication for ADHD, who tells you to take your medication?

  • My parents always remind me

  • Most of the time my parents remind me

  • Most of the time I do it on my own

  • I always remember it on my own

  • I do not take medication for ADHD


19. If you take prescription medication for ADHD: In the past 12 months, did you ever give or sell your medication to others?

  • Yes

  • No

  • I do not take medication for ADHD

III. Tobacco/Alcohol/Drug Use

These next few questions are very sensitive and ask you about drug use. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer.


20. Have you ever tried cigarette smoking, even one or two puffs?

  • Yes

  • No


21. How old were you when you smoked a whole cigarette for the first time?

  • I have never smoked a whole cigarette

  • 8 years old or younger

  • 9 or 10 years old

  • 11 or 12 years old

  • 13 or 14 years old

  • 15-16 years old

  • 17 years old or older



22. Do you currently smoke on a regular basis (at least once per week)?

  • Yes

  • No



23. Have you ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?

  • Yes

  • No



The next 5 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.


24. During your life, on how many days have you had at least one drink of alcohol?

  • 0 days

  • 1 or 2 days

  • 3 to 9 days

  • 10 to 19 days

  • 20 to 39 days

  • 40 to 99 days

  • 100 or more days


25. How old were you when you had your first drink of alcohol other than a few sips?

  • I have never had a drink of alcohol other than a few sips

  • 8 years old or younger

  • 9 or 10 years old

  • 11 or 12 years old

  • 13 or 14 years old

  • 15 or 16 years old

  • 17 years old or older






26. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?

  • 0 days

  • 1 day

  • 2 days

  • 3-5 days

  • 6-9 days

  • 10-19 days

  • 20 or more days


27. During the past 30 days, on how many days did you have at least one drink of alcohol on school property?

  • 0 days

  • 1 or 2 days

  • 3 to 5 days

  • 6 to 9 days

  • 10 to 19 days

  • 20 to 29 days

  • All 30 days



The next 4 questions ask about marijuana use. Marijuana is also called grass or pot.



28. During your life, how many times have you used marijuana?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 to 99 times

  • 100 times or more




29. How old were you when you tried marijuana for the first time?

  • I have never tried marijuana

  • 8 years old or younger

  • 9 or 10 years old

  • 11 or 12 years old

  • 13 or 14 years old

  • 15 or 16 years old

  • 17 years old or older


30. During the past 30 days, how many times did you use marijuana?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


31. During the past 30 days, how many times did you use marijuana on school property?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times



The next 9 questions ask about other drugs.



32. During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times






33. During the past 30 days, how many times did you use any form of cocaine including powder, crack, or freebase?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


34. During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


35. During your life how many times have you used heroin (also called smack, junk, or China White)?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


36. During your life, how many times have you used methamphetamines (also called speed, crystal, crank, or ice)?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times




37. During your life, how many times have you used ecstasy (also called MDMA)?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


38. During your life, how many times have you taken steroid pills or shots without a doctor’s prescription?

  • 0 times

  • 1 or 2 times

  • 3 to 9 times

  • 10 to 19 times

  • 20 to 39 times

  • 40 or more times


39. During your life, how many times have you used a needle to inject any illegal drug into your body?

  • 0 times

  • 1 time

  • 2 or more times


40. During the past 12 months, has anyone offered, sold, or given you any illegal drug on school property?

  • Yes

  • No


The next 7 questions ask about sexual behavior and are very sensitive. You can choose not to answer any of these questions. Remember these questions are private and we will not tell your parents how you answer.


41. Have you ever had sexual intercourse?

  • Yes

  • No





42. How old were you when you had sexual intercourse for the first time?

  • I have never had sexual intercourse

  • 11 years old or younger

  • 12 years old

  • 13 years old

  • 14 years old

  • 15 years old

  • 16 years old

  • 17 or more years old


43. During you life, with how many people have you had sexual intercourse?

  • I have never had sexual intercourse

  • 1 person

  • 2 people

  • 3 people

  • 4 people

  • 5 people

  • 6 or more people


44. During the last 3 months, with how many people did you have sexual intercourse?

  • I have never had sexual intercourse

  • I have had sexual intercourse, but not during the last 3 months

  • 1 person

  • 2 people

  • 3 people

  • 4 people

  • 5 people

  • 6 or more people


45. Did you drink alcohol or use drugs before you had sexual intercourse the last time?

  • I have never had sexual intercourse

  • Yes

  • No




46. The last time you had sexual intercourse, did you or your partner use a condom?

  • I have never had sexual intercourse

  • Yes

  • No


47. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy (Select only one)?

  • I have never had sexual intercourse

  • No method was used to prevent pregnancy

  • Birth control pills

  • Condoms

  • Depo-Provera (injectable birth control)

  • Withdrawal

  • Some other method

  • Not sure


48. How many times have you been pregnant or gotten someone pregnant?

  • I have never had sexual intercourse

  • 0 times

  • 1 time

  • 2 or more times




IV. Physical Activity


49. During the past 7 days, on how many days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?

  • 0 days

  • 1 day

  • 2 days

  • 3 days

  • 4 days

  • 5 days

  • 6 days

  • 7 days


50. During the past 7 days, on how many days did you exercise or participate in physical activity for at least 20 minutes that did not make you sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors?

  • 0 days

  • 1 day

  • 2 days

  • 3 days

  • 4 days

  • 5 days

  • 6 days

  • 7 days




51. During the past 7 days, on how many days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?

  • 0 days

  • 1 day

  • 2 days

  • 3 days

  • 4 days

  • 5 days

  • 6 days

  • 7 days


52. Do your parent(s) limit the amount of time that you spend watching television?

  • Yes

  • No


53. On an average school day, how many hours do you usually spend reading for fun (books/magazines/newspapers)?

  • I do not read for fun on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day


54. On an average school day, how many hours do you watch TV (or DVD/videos)?

  • I do not watch TV on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day





55. On an average school day, how many hours do you listen to music (radio/tapes/CDs/MP3s)?

  • I do not listen to music on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day


56. On an average school day, how many hours do you play with video or handheld games?

  • I do not play with video games on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day


57. On an average school day, how many hours do you use a computer for something that is not school work?

  • I do not use a computer for something that is not school work on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day




58. On an average school day, how many hours do you use more than one type of media at the same time (like music & computer, or TV & reading)?

  • I do not use more than one type of media on an average school day

  • Less than 1 hour per day

  • 1 hour per day

  • 2 hours per day

  • 3 hours per day

  • 4 hours per day

  • 5 or more hours per day


59. Do your parent(s) use internet filters or other methods of parental supervision when you are on the Internet or watching television?

  • Yes

  • No


60. Do you have access to R-rated movies and videos or mature rated video games?

  • Yes

  • No


61. Are there family rules about what television programs you are allowed to watch?

  • Yes

  • No


62. In an average week when you are in school, on how many days do you go to physical education (PE) classes?

  • 0 days

  • 1 day

  • 2 days

  • 3 days

  • 4 days

  • 5 days





63. How often do you participate in organized or team sports? (Include any teams run by your school or community)

  • I do not participate in organized sports

  • Daily

  • Twice a week

  • Weekly

  • Every other week

  • Once a month

  • Less than once a month


64. Compared to other children your age, do you consider yourself:

  • Much more active than other children

  • Somewhat more active than other children

  • About as active as other children

  • Less active than other children

  • Much less active than other children



V. Eating


65. During the past 7 days, how many times did your family eat a meal together?

  • Never

  • Once

  • Twice

  • 3 times

  • 4 times

  • 5 times

  • 6 times

  • 7 or more times

VI. Sleep Behavior


66. On a typical night, do you have trouble sleeping?

  • Yes

  • No



67. Do you snore?

  • Yes

  • No


68. Are you a restless sleeper?

  • Yes

  • No


69. Do you wake up during the night?

  • Yes

  • No


70. How many hours of sleep do you get on a typical night?

  • More than 8 hours

  • 6-8 hours

  • 4-5 hours

  • Less than 4 hours


71. Are you sleepy during the day?

  • Yes

  • No


VII. School Performance


72. Has someone from school or a doctor ever told you that you have a learning disability?

  • Yes

  • No


73. Do you consider yourself an:

  • A student

  • B student

  • C student

  • D student

  • F student


74. Do you worry about how you are doing right now or in the future?

  • Yes

  • No




VIII. Communication


75. How much have your parent(s) spoken with you about not smoking?

  • Not at all

  • Somewhat

  • A moderate amount

  • A great deal


76. How much have your parent(s) spoken with you about not drinking?

  • Not at all

  • Somewhat

  • A moderate amount

  • A great deal


77. How much have your parent(s) spoken with you about not using drugs?

  • Not at all

  • Somewhat

  • A moderate amount

  • A great deal




78. How much have your parent(s) spoken with you about birth control?

  • Not at all

  • Somewhat

  • A moderate amount

  • A great deal

79. How much have your parent(s) spoken with you about sexually transmitted diseases?

  • Not at all

  • Somewhat

  • A moderate amount

  • A great deal


FOR STUDY USE ONLY

Date Interviewed



Month Day Year

Interviewed by








File Typeapplication/msword
File TitleYouth Risk Behavior Survey
AuthorRobert McKeown
Last Modified ByAngelika Claussen
File Modified2007-06-28
File Created2007-06-26

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