Form #4 Adolescent Behavior and Communication Survey Baseline

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Participant Number: ______________

Adolescent Health Behavior and Communication Survey

This survey is about communicating with your doctors and your health behavior. It has been developed so you can tell us what you do that may affect your health. The information you give will be used to improve the services doctors provide young people like yourself.

DO NOT write your name on this survey. The answers you give will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). No one will know what you write. Answer the questions based on what you really do.

Completing the survey is voluntary. Whether or not you answer the questions will not affect the care you receive from your doctor. If you are not comfortable answering a question, just leave it blank.

The questions that ask about your background will be used only to describe the types of students completing this survey. The information will not be used to find out your name. No names will ever be reported.

Make sure to read every question. Unless a question states otherwise, please choose just one answer for each question.

When you are finished, mail the survey back in the postage-paid envelope provided.

Thank you very much for your help.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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. Form Approved: OMB Number 0935-XXXX  Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Communicating with Your Doctor

For each of the questions below, indicate your confidence on a scale of 1-5, where 1 is “not at all confident” and 5 is “very confident.”

Select one best answer for each question.

	Not at all Confident				Very Confident
A-1: On a scale of 1-5, how confident are you in your ability to make the most of your visit with a doctor?	 1	 2	 3	 4	 5
A-2: On a scale of 1-5, how confident are you in your ability to know what questions to ask a doctor?	 1	 2	 3	 4	 5
A-3: On a scale of 1-5, how confident are you in your ability to talk with your doctor about your eating habits?	 1	 2	 3	 4	 5
A-4: On a scale of 1-5, how confident are you in your ability to talk with your doctor about your physical activity?	 1	 2	 3	 4	 5
A-5: On a scale of 1-5, how confident are you in your ability to talk with your doctor about your sexual development and sexual health?	 1	 2	 3	 4	 5
A-6: On a scale of 1-5, how confident are you in your ability to talk with your doctor about tobacco?	 1	 2	 3	 4	 5
A-7: On a scale of 1-5, how confident are you in your ability to talk with your doctor about alcohol?	 1	 2	 3	 4	 5
A-8: On a scale of 1-5, how confident are you in your ability to talk with your doctor about drugs?	 1	 2	 3	 4	 5

Your Primary Care Doctor

A-9: How many times have you seen a primary care practitioner (family doctor, pediatrician, nurse practitioner, or physician assistant) in the last year?

• I have not seen a primary care practitioner in the last year

• 1 time

• 2 times

• 3 times

• 4 times

• 5 or more times

If A-91 is zero, skip to B-1 (About You)

In the following questions, “this doctor” refers to the primary care doctor you most recently saw.

A-10: During your most recent visit, did this doctor explain things in a way that was easy to understand?

• Yes, definitely

• Yes, somewhat

• No

A-11: During your most recent visit, did this doctor listen carefully to you?

• Yes, definitely

• Yes, somewhat

• No

A-12: During your most recent visit, did you talk with this doctor about any health problems or concerns?

• Yes

• No  If No, go to A-14

A-13: During your most recent visit, did this doctor give you easy to understand instructions about taking care of these health problems or concerns?

• Yes, definitely

• Yes, somewhat

• No

A-14: During your most recent visit, did this doctor show respect for what you had to say?

• Yes, definitely

• Yes, somewhat

• No

A-15: During your most recent visit, did this doctor spend enough time with you?

• Yes, definitely

• Yes, somewhat

• No

A-16: Using any number from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor possible, what number would you use to rate this doctor?

• 0 Worst doctor possible

• 1

• 2

• 3

• 4

• 5

• 6

• 7

• 8

• 9

• 10 Best doctor possible

A-17: Would you recommend this doctor’s office to your family and friends?

• Yes, definitely

• Yes, somewhat

• No

About You

B-1: How old are you?

• 12 years old

• 13 years old

• 14 years old

• 15 years old

• 16 years old

• 17 years old

• 18 years old

B-2: What is your sex?

• Female

• Male

B-3: Are you Hispanic or Latino?

• Yes

• No

B-4: What is your race? (Select one or more responses)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

B-5: In what grade are you?

• 9^th grade

• 10^th grade

• 11^th grade

• 12^th grade

• Ungraded or other grade

B-7: Do you have your own mobile phone?

• Yes

• No

B-7: In the last month, where have you used the internet? (Select all that apply)

• Using a computer at home

• Using a computer at school

• Using a computer in a library

• Using a laptop or netbook computer elsewhere

B-8: In the last month, have you used Facebook?

• Yes

• No

B-8: In the last month, have you used Twitter?

• Yes

• No

Your Intentions and Confidence

The following questions ask about what you intend to do, and how confident you are, about a variety of health behaviors.

C-1: How strong is your intention to get about 30 minutes of physical activity on most days for the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-2: How confident are you that you could get about 30 minutes of physical activity on most days for the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

C-3: How strong is your intention to eat five fruits and vegetables on most days in the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-4: How confident are you that you could eat five fruits and vegetables on most days in the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

C-5: How strong is your intention to avoid drinking beer, wine, or other alcohol in the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-6: How confident are you that you could avoid drinking beer, wine, or other alcohol in the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

C-7: How strong is your intention to avoid tobacco (cigarettes or chewing tobacco) in the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-8: How confident are you that you could avoid tobacco (cigarettes or chewing tobacco) in the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

C-9: How strong is your intention to avoid smoking marijuana in the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-10: How confident are you that you could avoid smoking marijuana in the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

C-11: How strong is your intention to either remain abstinent or use a condom every time you have sex during the next three months?

• Not at all strong

• Somewhat strong

• Pretty strong

• Extremely strong

C-12: How confident are you that you could either remain abstinent or use a condom every time you have sex in the next three months?

• Not at all confident

• Somewhat confident

• Pretty confident

• Extremely confident

Your Friends’ Behaviors

Questions D-1 through D-5 ask about your friends’ behaviors. Friends include friends you may have online. Although you may not know your friends’ behaviors for sure, for each question provide your best guess.

D-1: How often would you say your friends get at least 30 minutes of physical activity (enough to make you sweat and breathe hard)?

• Never

• 1-2 times each week

• About half the time

• Almost every day

• Every day

• Not sure/don’t want to answer

D-2: How often would you say your friends eat at least five fruits and vegetable servings a day?

• Never

• 1-2 times each week

• About half the time

• Almost every day

• Every day

• Not sure/don’t want to answer

D-3: About how many of your friends drank beer, wine, or other alcohol in the past three months?

• None

• Less than half

• About half

• More than half

D-4: About how many of your friends have used tobacco (cigarettes or chewing tobacco) in the past three months?

• None

• Less than half

• About half

• More than half

D-5: About how many of your friends have smoked marijuana in the past three months?

• None

• Less than half

• About half

• More than half

D-6: About how many of your friends would you say have had sex without using condoms in the past three months?

• None

• Less than half

• About half

• More than half

Your Eating Habits

E-1: On a typical day, how many times do you drink sweetened beverages such as sweet tea, punch, Kool Aid, sports drinks, or fruit drinks? Do not count 100% fruit juices.

• 1 or less

• 2 times

• 3 or more

• None

• Don’t know/not sure

E-2: On a typical day, how many times do you drink soda or pop (such as Coke or Pepsi)? Do not count “diet” soda.

• 1 or less

• 2 times

• 3 or more

• None

• Don’t know/not sure

E-3: How many times a week do you eat food from a fast food restaurant like Burger king, Chick-Fil-A, Bojangles, or Pizza Hut?

• Less than once a week

• Once a week

• 2 times a week

• 3 to 5 times a week

• More than 5 times a week

• Don’t know/not sure

E-4: On a typical day, how many times do you eat French fries or chips? (Chips are potato chips, tortilla chips, Cheetos, corn chips or other snack chips.)

• 1 or less

• 2 times

• 3 or more

• None

• Don’t know/not sure

E-5: On a typical day, how many glasses of milk do you drink? (A glass is the amount in a small carton or an 8 ounce drinking glass.)

• Less than 1 glass

• 1 glass

• 2 glasses

• 3 glasses

• 4 or more

• None

• Don’t know/not sure

E-6: What type of milk do you usually drink?

• Skim or Non-fat

• Low fat (1/2- 1%)

• Reduced fat (2%)

• Whole

• Don’t know/not sure

• Don’t drink milk

E-7: On a typical day, how many servings of vegetables do you eat? Do not include French fries. (A serving is ½ cup of cooked or raw vegetables, small salad, or ¾ cup of vegetable soup.)

• 1 or fewer servings

• 2 servings

• 3 or more servings

• None

• Don’t know/not sure

E-8: On a typical day, how many servings of fruit do you eat? (A serving is ½ cup of fresh fruit, 6 ounces of 100% fruit juice, a medium piece of fruit, or ¼ cup of dried fruit such as raisins.)

• 1 or fewer servings

• 2 servings

• 3 or more servings

• None

• Don’t know/not sure

Your Physical Activity

F-1: On an average weekday, how many hours do you watch TV?

______ hours

F-2: On an average weekday, how many hours do you play computer or video games?

______ hours

F-3: Over the past 7 days, on how many days were you physically active for at least 30 minutes per day?

______ days

F-4: Over the past 7 days, on how many days were you physically active for at least 60 minutes per day?

______ days

F-5: Over a typical or usual week, on how many days were you physically active for a total of at least 30 minutes per day?

______ days

F-6: Over a typical or usual week, on how many days were you physically active for a total of at least 60 minutes per day?

______ days

Your Tobacco Use

G-1: Have you ever tried or experimented with cigarette smoking, even a few puffs?

• No  If No, please skip to question G-3

• Yes  If Yes, please continue

G-2: Think about the last 30 days. On how many of these days did you smoke?

_________ days

G-3: During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?

• 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

Your Alcohol Use

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.

H-1: During the past 30 days, on how many days did you have at least 1 drink of alcohol? (If you do not drink write in 0)

____________ days

If H-1 is zero, skip to H-5

A drink of alcohol is a can or bottle of beer, a glass of wine, a can or bottle of wine cooler, 1 shot of liquor, or 1 cocktail.

H-2: On the days when you drank, about how many drinks did you usually drink?

____________ number of drinks

H-3: 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 to 5 days

• 6 to 9 days

• 10 to 19 days

• 20 or more days

H-4: During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?

• 0 times

• 1 time

• 2 or 3 times

• 4 or 5 times

• 6 or more times

H-5: During the past 30 days, how many times did you ride in a car or other vehicle driven by someone who had been drinking alcohol?

• 0 times

• 1 time

• 2 or 3 times

• 4 or 5 times

• 6 or more times

Your Drug Use

Question I-1 asks about marijuana use. Marijuana also is called grass or pot.

I-1: 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

The next 6 questions ask about other drugs.

I-2: 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

I-3: 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

I-4: 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

I-5: 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

I-6: 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

I-7: During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) 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

Your Sexual Behavior

The next 7 questions ask about sexual behavior.

J-1: Have you ever had sexual intercourse?

• No  If No, please skip to the end

• Yes  If Yes, please continue below

J-2: 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 years old or older

J-3: During your 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

J-4: During the past 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 past 3 months

• 1 person

• 2 people

• 3 people

• 4 people

• 5 people

• 6 or more people

J-5: Did you drink alcohol or use drugs before you had sexual intercourse the last time?

• I have never had sexual intercourse

• Yes

• No

J-6: The last time you had sexual intercourse, did you or your partner use a condom?

• I have never had sexual intercourse

• Yes

• No

J-7: The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? (Select only one response.)

• I have never had sexual intercourse

• No method was used to prevent pregnancy

• Birth control pills

• Condoms

• Depo-Provera (or any injectable birth control)

• Nuva Ring (or any birth control ring)

• Implanon (or any implant), or any IUD

• Withdrawal

• Some other method

• Not sure

Thank you again for completing this survey!

Please return it in the postage-paid envelope, even if you have left some questions blank.

Adolescent Health Behavior Survey Baseline v1.1 Mod: 10/5/2010