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I have trouble doing all of the family activities that I want to do
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I have trouble doing all of my usual work (include work at home)
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I have trouble doing all of the activities with friends that I want to do
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In the past 7 days how much did pain interfere with your day to day activities?
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In the past 7 days how much did pain interfere with work around the home
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In the past 7 days how much did pain interfere with your ability to participate in social activities?
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In the past 7 days how much did pain interfere with your household chores?
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Our records show that your child is now in [INSERT HEALTH PLAN NAME]. Is that right?
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What is the name of your child's health plan?
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In the last 6 months, did your child have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?
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In the last 6 months, when your child needed care right away, how often did your child get care as soon as you thought he or she needed?
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In the last 6 months, not counting the times your child needed care right away, did you make any appointments for your child’s health care at a doctor’s office or clinic?
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In the last 6 months, not counting the times your child needed care right away, how often did you get an appointment for health care at a doctor’s office or clinic as soon as you thought your child needed?
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In the last 6 months, not counting the times your child went to an emergency room, how many times did he or she go to a doctor’s office or clinic to get health care?
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In the last 6 months, how often did you have your questions answered by your child’s doctors or other health providers?
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Choices for your child’s treatment or health care can include choices about medicine, surgery, or other treatment. In the last 6 months, did your child’s doctor or other health provider tell you there was more than one choice for your child’s treatment or health care?
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In the last 6 months, did your child’s doctor or other health provider talk with you about the pros and cons of each choice for your child’s treatment or health care?
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In the last 6 months, when there was more than one choice for your child’s treatment or health care, did your child’s doctor or other health provider ask you which choice was best for your child?
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Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your child’s health care in the last 6 months?
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is your child now enrolled in any kind of school or daycare?