Questionnaire for parents to assess the health status of their child and its timely adjustment. Questionnaire for assessing the level of health on the main functional systems

Questionnaire for students in grades 1 - 10 "My daily routine"

Full name __________________________________ class _______

Guys! Read the questions and the suggested answers carefully. Monitor your daily routine during the week by recording each night the duration of the night's sleep, the time for doing homework and the time spent on a walk. Calculate the weekly average for all three questions. Choose the most appropriate number from the options provided. Write in the column "answers".

	Questions and Answers	Answers
	How long is your average night's sleep per week? Less than 9h Less than 9h30m From 10h25 to 9h30 10h30 or more
	How much time do you spend on homework on average per week? Less than 1h 1h30m or less From 1h to 1h30m From 1h35 to 2h Over 1h30m More than 2h
	How long does it take to walk outdoors (in hours and minutes) on average per week? 4 hours or more 3h30m or more 3 hours or more From 3h55m to 3h30m From 3h25m to 3h From 2h55m to 2h30m Less than 3h30m Less than 3h Less than 2h30m

Preview:

Questionnaire for parents "Health of my child"

FULL NAME._______________________________________________________________________

the class in which the son (daughter) studies ______________________________________________

Dear parents! Please read the content of the questionnaire carefully. Depending on the nature of the answer, you should underline Yes or no .

Questions		Answers
Are there headaches (unreasonable, with excitement, after school, after physical exertion).		Yes	No
Is there tearfulness?		Yes	No
Is there weakness, fatigue after classes at school and at home.		Yes	No
Whether there is a sleep disorder (poor falling asleep, sensitive sleep, bedwetting, difficult getting up).		Yes	No
Whether there is increased sweating or the appearance of red spots during excitement.		Yes	No
Are there dizziness, instability when changing the position of the body.		Yes	No
Are there fainting spells?		Yes	No
Are there pains, discomfort in the heart, palpitations, interruptions.		Yes	No
Has there ever been an increase in blood pressure.		Yes	No
Does it often happen:	runny nose	Yes	No
	cough	Yes	No
		Yes	No
Are there abdominal pains?		Yes	No
Do you have abdominal pain after eating?		Yes	No
Do you have abdominal pain before eating?		Yes	No
Whether there are nausea, an eructation, a heartburn.		Yes	No
Are there stool disorders (diarrhea, constipation).		Yes	No
Have you had dysentery?		Yes	No
Was there Botkin's disease (jaundice).		Yes	No
Do you have back pain.		Yes	No
Do you ever have pain when urinating.		Yes	No
Are there any reactions to any food, smells, flowers, dust, medicines (rash, swelling, difficulty breathing).		Yes	No
Whether there is a reaction to vaccinations (rash, swelling, difficulty breathing).		Yes	No
Are there often complaints of pain in the muscles after physical education, training?		Yes	No

The date ______________________

Signature of the person completing the questionnaire _______________________

Preview:

Questionnaire for students in grades 1-4 "Healthy lifestyle"

Class_______________ Gender M□ F □ Date of filling out the questionnaire _________________

1. Imagine that you have arrived at a summer camp. Your best friend, who came with you, left a bag with things at home and asks you to help. Check which of the following items should not be shared even with your best friend?

soap □ toothbrush □ hand towel□

washcloth □ toothpaste □ shampoo □

slippers □ body towel□

2. Two meal schedules were posted on the doors of the dining room - one of them is correct, and

Others contain errors. Check the correct timetable.

Breakfast	08.00	09.00
Dinner	13.00	15.00
afternoon tea	16.00	18.00
Dinner	19.00	21.00

3. Olya, Vera and Tanya cannot decide how many times a day they should brush their teeth. Which of the girls do you think is right? Mark the answer that you think is correct:

Teeth need to be brushed in the evenings to remove□

From the mouth, all the remnants of food accumulated during the day□

Teeth should be brushed in the morning and evening□

Brush your teeth in the morning to keep your breath fresh all day□

4. You were assigned to be on duty. You need to see how hygiene rules are followed by your friends. Under what circumstances would you advise them to wash their hands:

Before reading a book□ Before going to the toilet□

After going to the toilet□ After making the bed□

Before meals □ Before you go for a walk□

After playing basketball□ After playing with a cat or dog□

5. How often would you advise your friends to shower? Note:

Every day □ Two to three times a week□ Once a week □

6. Your friend hurt his finger. What would you advise him? Note:

Put your finger in your mouth□

Put your finger under the cold water faucet□

Spread the wound with iodine and cover with a clean napkin□

Preview:

Questionnaire for students in grades 5 - 7 "Healthy lifestyle"

Class_______________ Gender M□ F □ Date of filling out the questionnaire ___________________

1. Which of the following conditions do you consider the most important for a happy

life? Rate them on a scale from 8 (most important) to 1 (least important)

You).

have a lot of money□ Much to know and be able to□

Be healthy □ Have a job you love□

Have interesting friends□ Be beautiful, attractive□

Be self-reliant (to decide what to do and provide for yourself)□

Live in a happy family□

2. What conditions for maintaining health do you consider the most important?

From the above list of conditions, choose and mark the 4 most important for you.

Regular exercise□

Good rest □

Good natural conditions (clean air, water, etc.)□

Opportunity to be treated by a good doctor□

Money to eat well, relax, go to the gym, etc.□

Daily implementation of the rules of a healthy lifestyle

(compliance with the daily routine, regular meals, physical education, etc.)□

3. Which of the following is in your daily routine?

	Daily	Few times a week	Very rarely, never
Morning exercise, jogging
Breakfast
Dinner
Dinner
Walk in the fresh air
Sleep at least 8 hours
Sports
Shower, bath

4. Can you say that you care about your health? (tick as appropriate).

Yes, of course □ Rather yes than no□ Rather no than yes □ No□

Are you interested in learning about how to take care of your health? Mark one

Answer.

Yes, very interesting□ More interesting than not□

More uninteresting than interesting□ Not interested □

How do you learn about how to take care of your health?

	Often	From time to time	Never
At school
Houses
From friends
From the Internet

How do you rate the health information you learn...

	Interesting	Not always interesting	Not interested
At school
Houses
From friends
From the Internet
From radio and television broadcasts

8. What health promotion activities do you have in your classroom?

Which of them do you find interesting and useful?

	Held	Interesting	Not interested
Health Lessons
Lectures on how to take care of your health
Showing films about how to take care of your health
Sport competitions
Quizzes, competitions, games on the topic of health
Holidays, evenings on the topic of health

Preview:

Questionnaire for students in grades 8 - 11 "Healthy lifestyle"

Class_______________ Gender M□ F □ Date of filling out the questionnaire ______________________

1. Which of the values below are most important to you?

Material well-being□

Quality education□

Attractive appearance□

Good health□

Opportunity to communicate with interesting people□

Wealthy family□

Freedom and independence (the ability to plan your own life and realize desires)□

Favorite job □

2. What conditions for maintaining health do you consider the most important? From the above

Select the list of conditions and mark the four most important to you.

Good heredity□

Good environmental conditions□

Compliance with the rules of a healthy lifestyle (mode, exercise, etc.)□

Possibility of consultation and treatment with a good doctor□

Knowledge about how to take care of your health□

Absence of physical and mental overload□

Regular exercise□

Sufficient material resources for good nutrition, sports, etc.□

3. Which of the following is in your daily routine?

	Daily	Few times a week	Very rarely
Morning exercise, jogging
Breakfast
Dinner
Dinner
Walk in the fresh air
Sleep at least 8 hours
Sports
Shower, bath

4. Are you taking care of your health enough?

Quite enough□ Not quite enough□ Not enough □

5 How do you feel about information about how to take care of your health?

Very interesting and helpful□ Quite interesting and useful□

Not very interesting or helpful□ Not interested and not needed□

6 How do you learn about how to take care of your health?

Indicative estimate health status of students at school

Conducting regular diagnostics of the health status of schoolchildren is extremely difficult, if not impossible. Therefore, such diagnostic materials that can be carried out by schoolchildren themselves and their teachers are of great relevance. Of course, the diagnostic materials presented below cannot replace a medical examination and therefore are of an indicative nature, however, they allow not only obtaining data for entering into individual student cards, but also increasing the interest of schoolchildren in improving their own health.

For a general assessment of health as a reserve of the body's adaptive capabilities, numerous approaches and methods are proposed.

1. Test questionnaire for an approximate risk assessment of student health disorders

Held cool m leader

Instruction to the expert

Try to rate the student on the following items using a 4-point scale:

signs

1. Since childhood, there have been manifestations of poor health, morbidity.

2. Previously endured serious illnesses, injuries, operations.

3. Growing up in a dysfunctional family.

4. The family has financial difficulties.

5. Characteristically antisocial environment (friends, neighbors, relatives).

6. Leads an incorrect (unhealthy) lifestyle.

7. Leads a sedentary lifestyle (lack of physical activity).

8. Differs in low intellectual level.

9. Differs in a low cultural level, a narrow range of interests.

10. Unformed hygienic skills are characteristic.

11. Carefree, irresponsible.

12. Shows asthenic character traits, weak will.

13. Shows no interest in improving his health.

14. Differs in low search activity, lack of initiative.

15. Has a highly excitable nervous system, prone to stress.

16. Has a bad relationship with teachers.

17. Increased fatigue is characteristic.

18. Uses (used in the past) intoxicating substances.

20. Makes frequent health complaints.

Interpretation of results

Favorable can be considered indicators in the range of 20-25 points. Indicators of more than 40 points are the basis for classifying a student as a risk group. FROM comparative analysis of indicators of students of different classes.

results

2. Test questionnaire for an approximate assessment of the risk of visual impairment

T The meal was held by the student's parents.

Instruction to the expert

Try to rate the child on the following items using a 4-point scale:

0 - sign is not expressed (absent);

1 - the sign is weakly expressed or appears occasionally;

2 - the sign is moderately expressed or appears periodically;

3 - the sign is clearly expressed or manifests itself constantly.

signs

1. Reads a lot.

2. Often reads in poor light or lying down.

3. Spends more than an hour (half an hour for younger students) a day at the computer.

4. Spends more than two hours (1 hour for younger students) watching TV a day.

5. Reads, writes "with his nose" in the text.

6. Parents have poor eyesight (wear glasses).

7. Wrong diet (lack of vitamin A).

8. There is a tendency of increased arterial and/or intracranial pressure.

9. Carelessly refers to the hygiene of vision, does not monitor eye fatigue.

results

3. Test questionnaire for an approximate assessment of the risk of scoliosis and other postural disorders

The instruction is the same as in the previous test questionnaire.

signs

1. Has a habit of sitting, lying in wrong positions.

2. Carries bags, briefcase in one hand.

3. Has a habit of slouching.

4. Shows insufficient physical activity.

5. Does not engage in recreational gymnastics (physical exercise, participation in sports sections, swimming).

6. Engaged in weightlifting (weight lifting).

7. Incorrect or irregular eating.

8. Has an asthenic, disproportionate physique.

9. Carelessly, carelessly refers to their health, their appearance.

10. Has pronounced features of inertia, slowness, phlegm.

Interpretation of the results for two test questionnaires: a favorable indicator for each of the questionnaires is up to 10 points, with an indicator of more than 20 points, the student should be classified as a risk group.

results

4. Test questionnaire for self-assessment by schoolchildren of risk factors for poor health

The test questionnaire is filled in by each student independently. A test form for (boys) is provided. From the test questionnaire for (girls) question 6 is excluded.

Questions 1-10 are supposed to be answered "yes" or "no"; questions No. 11-15 provide for the choice of one of the proposed answers.

Questions

1. I often sit hunched over or lie down with a twisted back.

2. I carry a briefcase, a bag (often heavy), not a knapsack.

3. I have a habit of slouching.

4. I feel that I am not moving enough (not enough).

5. I do not do recreational gymnastics (physical exercises, participation in sports sections, swimming).

6. I do weightlifting (weight lifting).

7. I eat irregularly, "somehow."

8. I often read in poor lighting while lying down.

9. I don't care about my health.

10. Sometimes I smoke.

11. Does the school help you take care of your health?

c) find it difficult to answer.

12. Did schooling help you create a healthy lifestyle at home?

c) find it difficult to answer.

13. What are the most typical states for you in the classroom?

a) indifference

b) interest;

c) fatigue, fatigue;

d) concentration;

e) excitement, anxiety;

e) something else.

14. How do you think teachers affect your health?

a) take care of my health;

b) cause harm to health by the methods of their teaching;

c) set a good example;

d) setting a bad example;

e) teach how to protect health;

f) They don't care about my health.

15. How do you think the environment at school affects your health?

a) has no significant effect;

b) influence badly;

c) influences well;

d) find it difficult to answer.

Results processing

For questions 1-10, one point is awarded for each positive answer. For questions 11-12, a point is awarded for the answer "b". For question 13, points are awarded for answers "a", "c", "e". For question 14, points are awarded for answers “b”, “d”, “e”. For question 15, points are awarded for answers "b", "d". The scores are then added up.

Interpretation of results

A score of no more than 6 points is considered successful. "Risk zone" - more than 12 points.

results

Change your biological age. Back to 25 Semyon Lavrinenko

Annex 1. Questionnaire for objective health assessment

The formula for determining the biological age in women:

BVzh \u003d -1.463 + 0.415? ADR - 0.141? SB + 0.248 ? MT + 0.694? POPs

ADr - The difference between the indicators of the upper and lower pressure.

SB - static balancing in seconds. The subject stands on the left leg, without shoes, arms lowered along the body until the right leg touches the floor. It is measured three times, the interval between measurements is 5 minutes. The best score is taken into account.

BW is body weight in kilograms.

POPs - subjective assessment of health. Answers to 28 questions must sound either "yes" or "no").

PPH Questionnaire (subjective health assessment)

1. Do you suffer from headaches?

2. Can you say that you easily wake up from any noise?

3. Do you suffer from pain in the region of the heart?

4. Do you think that your eyesight has deteriorated in recent years?

5. Do you feel that your hearing has deteriorated in recent years?

6. Do you try to drink only boiled water?

7. Do they give you a seat in public transport?

8. Do you suffer from joint pain?

9. Do you go to the beach?

10. Does the change in the weather affect your well-being?

11. Do you have periods when you lose sleep due to anxiety?

12. Do you suffer from constipation?

13. Do you feel that you are now as efficient as before?

14. Do you suffer from pain in the liver area?

15. Do you get dizzy?

16. Do you find it harder to focus now than in recent years?

17. Are you worried about the weakening of memory, forgetfulness?

18. Do you feel burning, tingling, crawling in different parts of the body?

19. Do you have periods when you feel joyfully excited, happy?

20. Do you suffer from ringing or noise in your ears?

21. Do you keep one of the following medicines in your home medicine cabinet: validol, nitroglycerin, heart drops?

22. Do you have swelling in your legs?

23. Do you have to give up certain foods?

24. Do you have shortness of breath when walking fast?

25. Do you suffer from pain in the lumbar region?

26. Do you have to take any mineral water for medicinal purposes?

27. Do you have a bad taste in your mouth?

28. Can you say that you began to cry easily?

29. How do you rate your health? (good, fair, poor, very poor).

Treatment of results:

Answers "Yes" to questions Nos. 1-8, 10-12, 1418, 20-28.

Answers "No" to questions No. 9, 13, 19.

For question No. 29, one of the last two answers is considered unfavorable.

We count the total number of unfavorable responses (it can range from 0 to 29), substitute it into the formula for determining biological age.

EXAMPLE:

Determine the biological age for a woman whose passport age is 37 years old, who has the following parameters:

BP = 120 mm Hg. st,

BP (lower) = 80 mm Hg Art.,

POPs = 18 adverse responses.

Substitute in the formula:

BVzh \u003d -1.463 + 0.415? 40 - 0.141? 50 + + 0.248? 61+ 0.694? eighteen.

As a result, we get that the biological age is 35.7 years.

From the book Frantic Search for Self the author Grof Stanislav

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From the book History of Psychology by Roger Smith

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DONOR CODE:_________________________________________________

HEALTH QUESTIONNAIRE.

We use this questionnaire to determine your eligibility to donate according to medical guidelines that protect your health as a potential donor, as well as the health of the patient. The questions address many of the factors that may prevent a person from joining the Register from a medical point of view. The questions listed below do not include all situations that prohibit a person from donating, so if you have a dispute or doubt about your suitability, please contact the Registry staff.

We kindly ask you to fill in the following form in detail and in good faith:

1. General questions

Have you had any pregnancies?** yes; no.

If yes, how many times _________.

Your blood type and Rh factor (if known) ____________________

Have you had a blood transfusion?** yes; No

if “yes”: what overflowed _________________ when (year) __________ how many times _________

Do you have allergies? Yes; No

if yes, what allergens _________________________________________________________

Your height ___________ (cm.) Your weight ____________ (kg.)

Do you smoke? ** Yes; No

Do you drink alcohol regularly? Yes; No

Have you ever been a blood donor?** yes; No

Have you ever been suspended from donating? Yes; No

If “yes”, what was the reason: __________________________________________________________ .

Are you currently taking any medications? Yes; No

If “yes”, what medications __________________________________________________________.

Have you had surgery in the last year? Yes; No

If “yes”, which ones _______________________________________________________________________.

Have you had unexplained fevers? Yes; No

Have you been in a serious accident? Yes; No

Have you had any recent vaccinations? Yes; No

2. Do you currently suffer from or have you previously suffered from the following diseases:


			Tumors (including cured)
			Diabetes mellitus requiring drug treatment
			Bronchial asthma or chronic obstructive bronchitis requiring ongoing treatment
			High blood (arterial) pressure
			Heart disease: ischemic heart disease, angina pectoris, arrhythmia, myocardial infarction in the past
			Blood vessel disease: previous stroke, arterial thrombosis, recurrent venous thrombosis
			Blood clotting disorders: increased bleeding or increased blood clotting
			hereditary blood diseases
			Severe kidney disease
			Thyroid disease
			Autoimmune diseases: Crohn's disease, rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus and others.
			Diseases of the nervous system (cramps, problems with the intervertebral discs, in particular a displaced or damaged disc)
			Mental problems (depression or other conditions)
			HIV infection (AIDS)
			Acute or chronic viral hepatitis

			Tuberculosis

			Infectious diseases: leprosy, babesiosis, trypanosomiasis (Chagas disease), encephalitis, malaria, brucellosis, rickettsiosis, tularemia
			Have you been treated with pituitary hormones, in particular growth hormones.
			Have you had a tissue or organ transplant?

			Has any of your immediate family members had leukemia (leukemia)**
			Have any of your immediate family members had cancer or other malignant neoplasms**
			Has anyone in your family had Creutzfeldt-Jakob disease?

3. Questions related to the risk of HIV, hepatitis B and C infections:

1. Are you familiar with the information on AIDS (HIV) and hepatitis?** yes; No

2. Do you understand this information? ** Yes; No

3. Have you been or are you currently exposed to the possibility of contracting HIV, hepatitis B or C through contact with a family member or at work? Yes; No

If you are at risk of HIV infection or hepatitis B and C, you will not be allowed to donate for a period of time. It also includes sexual and other close contact with a person infected with this infectious disease. The following conditions may prevent you from becoming a donor:

a) drug use;

b) sexual contacts in exchange for receiving money or drugs;

c) homosexual contacts for men;

d) for women: sexual relations with a man who had homosexual contacts in the past;

e) sexual contact in the last 12 months with a partner who:

Is HIV positive or has hepatitis B or C;

Has taken or is taking drugs;

Had sex in exchange for money or drugs.

4. Questions related to the risks of anesthesia:

1. Have you ever had general anesthesia?** yes; No

2. If yes, did you have any complications or reactions? Yes; No

If “yes”, please specify: _________________________________________________________ .

3. Have any of your relatives experienced problems related to

with general anesthesia?** yes; No

5. Other points

Do you have any other concerns or health issues that may prevent you from becoming a donor that you would like to discuss? (Please specify) _______________

________________________________________________________________________________________ .

If you answered “yes” to one or more questions (except for questions marked with **), or if you doubt your suitability, please contact our Register staff.

I certify that I have not suffered and do not suffer from serious, long-term illnesses, and, to the best of my knowledge, I am completely healthy.

_____________________ (date) _________________________ (signature)