To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment (he/she) received because of the incident? Yes Review the medical records release form with the respondent and collect their signature No Child Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that [Child’s name] has any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Yes (Please specify)___________________ No Allergies? Unsure Yes No Asthma? Unsure Yes No Diabetes? Unsure Yes No High blood pressure? Unsure Yes (Please specify)___________________ No Physical disability that hinders mobility? Unsure Yes (Please specify) No Psychological condition such as depression? Unsure Yes (Please specify) _________________ No Cancer? Unsure Yes No Neurological conditions such as cerebral palsy? Unsure Yes Developmental conditions such as ADHD/ADD or autism? No
To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment (he/she) received because of the incident? Yes Review the medical records release form with the respondent and collect their signature No Child Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that [Child’s name] has any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Allergies? Yes (Please specify)___________________ No Unsure Asthma? Yes No Unsure Diabetes? Yes No Unsure High blood pressure? Yes No Unsure Physical disability that hinders mobility? Yes (Please specify)___________________ No Unsure Psychological condition such as depression? Yes (Please specify) No Unsure Cancer? Yes (Please specify) _________________ No Unsure Neurological conditions such as cerebral palsy? Yes No Unsure Developmental conditions such as ADHD/ADD or autism? Yes No
General%20Survey.docx