Self Administered Forms (Mother)

The Study to Explore Early Development (SEED) - Phase 3

Attachment 8.c. Child Health History Form SEED 3

Self Administered Forms (Mother)

OMB: 0920-1171

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Attachment 8.c.

Form Approved

OMB No. 0920-XXXX

Exp. Date:  XX/XX/2020


Study ID #: ______________

Date of Completion___________


Study to Explore Early Development


CHILD HEALTH HISTORY


Respondent’s relationship to the study child:


Biological Mother Biological Father Other: Specify ___________________­­­­­­­­­­­­­­­



How many full siblings does your child have*:______ How many half siblings*:______


  • Full siblings are brothers and sisters that have the same biological mother AND same biological father as your child.

  • Half siblings are brothers and sisters who have the same biological mother OR same biological father as your child.






SECTION A: CONDITIONS DIAGNOSED BY A DOCTOR


In the following two tables, please tell us if your child has ever been diagnosed by a doctor or other health care provider with any of these conditions.


See the enclosed glossary of terms if you don’t know the meaning of a condition.


If you check “Yes,” tell us the age at diagnosis.


For the chronic conditions in the first table, we also would like to know how many full siblings and how many half siblings have each condition


For some allergies and infections in the second table, we also ask that you tell us the specific type of allergy or number of times your child had the infection.



Section A.1. Chronic Conditions




Enrolled CHILD


SIBLINGS


Doctor or other health care provider has diagnosed the condition?

Doctor or other health care provider has diagnosed the condition?


No/ Don’t Know

Yes

Age at Diagnosis

(in years)


(Write <1 if younger than 1 year)

If any have been diagnosed, please write in the number of siblings with this condition. If your child has no siblings or none of the siblings have the condition, mark None

Addison’s Disease


_____ # Full _____# Half ____None

Ankylosing spondylitis


_____ # Full _____# Half ____None

Aplastic anemia


_____ # Full _____# Half ____None

Asthma


_____ # Full _____# Half ____None

Autoimmune hepatitis


_____ # Full _____# Half ____None

Bleeding/Clotting Disorder


_____ # Full _____# Half ____None

Cancer


_____ # Full _____# Half ____None

Celiac Disease


_____ # Full _____# Half ____None

Congenital Heart Defect/ Cardiovascular condition


_____ # Full _____# Half ____None

Crohn’s Disease


_____ # Full _____# Half ____None

Cystic Fibrosis


_____ # Full _____# Half ____None

Dermatitis herpetiformis


_____ # Full _____# Half ____None

Diabetes: Uses insulin


_____ # Full _____# Half ____None

Diabetes: Does not use insulin


_____ # Full _____# Half ____None

Eczema/psoriasis


_____ # Full _____# Half ____None

Feeding Disorder


_____ # Full _____# Half ____None

Giant cell arteritis


_____ # Full _____# Half ____None

Graves disease


_____ # Full _____# Half ____None

Gullain-Barre Syndrome


_____ # Full _____# Half ____None

Hashimoto thyroiditis


_____ # Full _____# Half ____None

Hemolytic anemia


_____ # Full _____# Half ____None

Hyperthyroidism


_____ # Full _____# Half ____None

Hypothyroidism


_____ # Full _____# Half ____None

Irritable bowel syndrome


_____ # Full _____# Half ____None

Lupus, or systemic lupus erythematosus (SLE)


_____ # Full _____# Half ____None

Migraine headaches


_____ # Full _____# Half ____None

Mixed connective tissue disease


_____ # Full _____# Half ____None

Multiple sclerosis


_____ # Full _____# Half ____None

Myasthenia gravis


_____ # Full _____# Half ____None

Narcolepsy


_____ # Full _____# Half ____None

Optic neuritis


_____ # Full _____# Half ____None




Enrolled CHILD


SIBLINGS


Doctor or other health care provider has diagnosed the condition?

Doctor or other health care provider has diagnosed the condition?


No/ Don’t Know

Yes

Age at Diagnosis

(in years)


(Write <1 if younger than 1 year)

If any have been diagnosed, please write in the number of siblings with this condition. If your child has no siblings or none of the siblings have the condition, mark None

Pemphigus


_____ # Full _____# Half ____None

Reiter’s syndrome


_____ # Full _____# Half ____None

Rheumatoid arthritis


_____ # Full _____# Half ____None

Scleroderma (progressive systemic sclerosis, CREST)


_____ # Full _____# Half ____None

Sickle cell anemia/ thalassemia/other hereditary anemias


_____ # Full _____# Half ____None

Sjogren’s syndrome


_____ # Full _____# Half ____None

Stevens-Johnson syndrome


_____ # Full _____# Half ____None

Sydenham’s chorea


_____ # Full _____# Half ____None

Thrombocytopenia, (immune, idiopathic)


_____ # Full _____# Half ____None

Ulcerative colitis


_____ # Full _____# Half ____None

Other condition (specify):



_____ # Full _____# Half ____None

Other condition (specify):



_____ # Full _____# Half ____None

Other condition (specify):



_____ # Full _____# Half ____None




Section A.2. Allergies and Infections

For the allergies and infections below, please mark whether or not the enrolled child has, or had, the condition. For some of the allergies and infections, please also write in the specific type of allergy or number of times the enrolled child had the infection.



Enrolled CHILD


Doctor or other health care provider has diagnosed the condition?



No/ Don’t Know

Yes

Specify type or number of times (as indicated)

Age at 1st Diagnosis

(years)

(Write <1 if younger than 1 year)

Allergy, Drug (specify type)



Allergy, Food (specify type)



Allergy, Hay Fever



Allergy, Skin (specify type)



Allergy, Other (specify type)



Chicken Pox



Cytomegalovirus



Ear Infection, Recurrent (specify # of times)




Enrolled CHILD


Doctor or other health care provider has diagnosed the condition?



No/ Don’t Know

Yes

Specify type or number of times (as indicated)

Age at 1st Diagnosis

(years)

(Write <1 if younger than 1 year)

German Measles or Rubella



Group A Strep (includes Strep Throat and Scarlet Fever) (specify # times)



Group B Strep (GBS)



Hepatitis A



Hepatitis B



Hepatitis C



Hepatitis, Unknown type



Herpes Infection



HIV or AIDS



Impetigo (specify # times)



Influenza (specify # times)



Lyme Disease



Measles



Meningitis, Bacterial



Meningitis, Viral



Meningitis, Unknown Type



Mumps



Parvovirus or Fifth Disease



Pneumonia (specify # times)



Respiratory Synctial Virus or RSV



Tetanus



Tonsillitis (specify # times)



Toxoplasmosis



Tuberculosis



Urinary Tract Infection or UTI (specify # times)



Other Infection (specify type)



Other Infection (specify type)



Other Infection (specify type)





Has your child ever had an allergic reaction that required medical attention such as an office contact (by telephone or in-person visit) or hospitalization?

Yes No Don’t Know


SECTION B: GASTROINTESTINAL SYMPTOMS (answer all 3 questions)


  1. Has your child taken medication for gastrointestinal problems regularly within the past year? Regularly means at least once per month for at least 3 months within the past year.

This can include a medicine prescribed by a doctor or an over the counter medication, such as TUMS or Miralax.

No

Yes Specify all medications, what they are treating, and how often your child took the medication in the past year.


Medications:

Reason for taking medications:

Often


(daily or almost daily)

Sometimes


(1-2 times per week)

Rarely

(less than once per week

1.


2.


3.


4.


5.




2. Tell us how often your child has had the following problems



How often has child had the issue in the past 12 months?


(Choose ONE for each issue)



Often


(4 or more times per month)


Sometimes



(2-3 times per month)


Rarely/

Never


(once per month or less)



Don’t Know


Vomiting not associated with illness

Diarrhea not associated with illness

Constipation

Abdominal pain not associated with diarrhea or constipation

Gastroesophageal reflux

Pain on stooling or having a bowel movement

Eats a limited variety of foods

Abdominal distension or tummy bloating

Gaseousness

Passage of unformed/loose or watery stools

Passage of hard, pebble like stools

Other gastrointestinal problem, specify: ___________________________



3. How many stools does your child usually have currently?

Less than 3 stools per week 0-1 stools per day and 3 or more stools per week

2-3 stools per day Don’t know


SECTION C: SLEEP CHARACTERISTICS (answer all 3 questions)


  1. Has your child taken medication for sleep difficulty or sleep disorder regularly within the past year? Regularly means at least once per month for at least 3 months within the past year

This can include a medicine prescribed by a doctor or an over the counter medication, such as melatonin.

No

Yes Specify all medications, what they are treating, and how often your child took the medication in the past year.


Medications:

Reason for taking medications:

Often


(daily or almost daily)

Sometimes


(1-2 times per week)

Rarely

(less than once per week)












2. Tell us how often your child has had the following problems.


How often has child had problem in past 12 mths?


(Select one of the following)


Often


(5 days per week or more )


Sometimes


(2-4 days per week)


Rarely/ Never


(one day per week or less)



Don’t Know


Takes more than 20 minutes to fall asleep

Does not falls asleep alone in own bed

Moves to someone else’s bed during the night (e.g., parent, brother, sister)

Is restless or moving a lot during sleep

Seems to stop breathing during sleep

Grinds teeth during sleep (your dentist may have told you this)

Snores during sleep

Wakes during night screaming, sweating, and inconsolable

Wakes once per night

Wakes more than once per night

  • If your child sometimes or often wakes once or more per night: How long does your child typically stay awake before going back to sleep (within the past year)? ________________minutes

Wakes very early in the morning

Takes a long time to become alert in the morning

Other sleep problem, Specify ___________________________



  1. On a typical weekday, what time does your child:


Go to bed at night? ___________ Wake up in the morning? _____________


SECTION D: HEALTH INSURANCE AND HEALTH CARE


  1. Does your child currently have any of the following types of health insurance coverage?

(Choose YES or No for each option. Select No/Don’t Know if you are not sure. Include health insurance through you or someone else):


Yes

No/ Don’t Know

Private insurance including HMOs (provided through a job or private purchase)

Government plans (e.g., Medicaid or the Children’s Health Insurance Program (CHIP)

Other type of insurance, specify _________________________________________

Child is currently uninsured


  1. During the past 12 months, was there any time when your child was not covered by ANY health insurance? Yes No Don’t Know


  1. Other than the emergency room, is there a place that you USUALLY take your child when he or she is sick or you need advice about his or her health?

Yes, one usual place Yes, but more than one usual place No Don’t Know

A personal doctor or nurse is a health professional who is familiar with your child’s health history. This can be a general doctor (“GP”), a family practice doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician’s assistant.


  1. Do you have one or more persons you think of as your child’s personal doctor or nurse?

Yes, one person Yes, more than one person No Don’t Know


  1. During the past 12 months did your child need a referral to see any doctors or receive any services? Yes No Don’t Know

5a. If YES, was getting referrals: A big problem A small problem Not a problem


Care coordination means that someone helps you make sure that your child gets all the health care and services needed and that health care providers share information.


  1. During the past 12 months, how often did you get as much help as you wanted with arranging and coordinating your child’s care among the different doctors or services that he or she uses?

Never Sometimes Usually Always Don’t Know I didn’t need any help


  1. During the past 12 months, how often did your child’s doctors and other health care providers spend enough time with him or her?

Never Sometimes Usually Always Don’t Know

I didn’t see my child’s health care providers in past 12 months


Information about a child’s health or health care can include things such as the causes of any health problems, how to care for a child now, and what changes to expect in the future.


  1. During the past 12 months, how often did you get the specific information you needed from your child’s doctors and other health care providers?

Never Sometimes Usually Always Don’t Know

I didn’t see my child’s health care providers in past 12 months



Public reporting burden of this collection of information is estimated to average 30 minutes, 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0010).


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