Allen Moulton - Health Survey

I am in the process of trying to manage a survey on health care. The questionaire is available either in Adobe Acrobat Reader format here: Health Survey, PDF, 13 KB (The latest, free version of Adobe Acrobat Reader is available HERE.), or in HTML format below.

YOUTH HEALTH SURVEY

This health survey is about health care concerns in students from grades 5 to 8. There are 10 statements; you are asked to agree or disagree with each one. If you choose to complete the form you will find there is no space for your name- the information will be completely private. The information from this form can help in understanding how many students have concerns about an important part of health care. There is a space at the bottom of the form if you want to say more about your health care concerns. Please speak with your parents, the school nurse or school guidance counselor if you feel you need help with any health care concerns.

Thank you,
Allen Moulton, M.S., R.N., M.S.N.
Licensed Psychologist-Masters
Masters Child Health Nurse

HEALTH SURVEY
Please mark a circle across from each item showing that you agree or disagree with each statement. Mark only one circle for each item. If you would like to say more about how you feel about health care you can do so at the bottom of the page. Thank you.
	Agree	Disagree
1. I like going to visit my doctor's office.	O	O
2. Going to my doctor's office worries me a little but only when I'm there.	O	O
3. When there, I worry only in the doctor's exam room.	O	O
4. When there, I worry in the waiting room and in the doctor's exam room.	O	O
5. I worry about visits to my doctor's office during the day before I go.	O	O
6. I worry about going to my doctor's office several days before I go.	O	O
7. I get very upset (scared, crying or yelling) when I have to go to my doctor's office.	O	O
8. It's hard for me to do homework or have fun with my friends when I know I am going to my doctor's office soon.	O	O
9. The part I am afraid of most about my doctor's office is shots (needles).	O	O
10. What upsets me most about going to the doctor's office is ___________.	O	O
Other Comments:_______________________________________________ _____________________________________________________________.
Thank you for your help with this survey.

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