School-Based Health Centers – Implementation Tools

Your:      Age _____ Sex _____ Grade _____

Medical sick visits. This section of questions is about medical sick visits, which are visits to see the doctor because of an injury or illness (for example, a sore throat or twisted ankle).

1. Do you have a doctor, nurse practitioner, or physician’s assistant to go to when you are ill or hurt?

  • 1-Yes
  • 2-No

1a. I usually see (check one)

  • 1-Doctor
  • 2-Nurse Practitioner
  • 3-Physician’s Assistant 4-Don’t Know

2. Where do you go when you are sick or injured (bad sore throat or twisted ankle)?

  • 1-I go to my Doctor, Nurse Practitioner or Physician’s Assistant
  • 2-If I can, I go to my doctor but use the emergency room if that’s not possible.
  • 3-If I can, I go to my doctor but use the immediate care center if that’s not possible
  • 4-I go to an emergency room
  • 5-I go to an immediate care center
  • 6-I don’t go

3. How is your medical care for sick visits paid for?

  • 1-Family private insurance
  • 2-Medicaid
  • 3-Our family pays it all/no insurance
  • 4-Don’t know

4. Have you ever wanted to see a doctor about an illness or injury but were unable to?

  • 1-Yes
  • 2-No

4a. If you were unable to see a doctor, WHY?

  • 1-No insurance or money to pay for visit
  • 2-No way to get to doctor’s office
  • 3-Don’t know how to get an appointment
  • 4-Don’t feel comfortable with my doctor
  • 5-My parents didn’t think I needed to go
  • 6-No way to go without my parents being involved
  • 7-Don’t know any doctors
  • 8-Other (please describe) ______________________________

5. If you had a medical problem or needed medical information but didn’t know where to go, how would you get help? (Check all that apply)

  • 1-Parent
  • 2-Library
  • 3-Teacher
  • 4-Hotline
  • 5-Friend
  • 6-Doctor, Nurse Practitioner, Physician’s Assistant
  • 7-Guidance Counselor
  • 8-Health Teacher
  • 9-School Nurse
  • 10-Phone Book
  • 11-Other (please describe) _______________________________

6. Have you ever wanted to talk about an emotional problem with a mental health professional (counselor, psychologist, social worker or psychiatrist) ?

  • 1-Yes
  • 2-No

6a. If you wanted to see a mental health professional, but were unable to, why:
(Skip this question if you were able to see a mental health professional)

  • 1-No insurance or money to pay for visit
  • 2-No way to get to mental health professional’s office
  • 3-Don’t know how to get an appointment
  • 4-Uncomfortable making an appointment
  • 5-My parents didn’t think I needed to go
  • 6-No way to go without my parents being involved
  • 7-Don’t know any mental health professionals
  • 8-Other (please describe) _______________________________

6b. If you have seen a mental health professional, where do you go?

  • 1-school counselor
  • 2-mental health center
  • 3-other therapist/counselor

6c. Were you satisfied with the care you received?

  • 1-Yes
  • 2-No

Comments:

Medical Checkups: This section is about check up visits, which are visits for a complete physical examination, like a yearly checkup or a sports physical. You go to the doctor at a time when you are basically healthy; your height, weight and blood pressure are checked and your general overall health may be discussed.

7. Do you have a doctor or other health care provider to go to for a checkup?

  • 1-Yes
  • 2-No
Column A

(If you answered YES to question 7)
If you do have a doctor or other health care provider for checkups:

8a. What kind of health care provider do you see most often? (CHECK ONE)

  • 1-Family doctor/practitioner
  • 2-Pediatrician (a doctor who sees babies, children and teens)
  • 3-Internist (a doctor who sees only teens and adults)
  • 4-Nurse Practitioner
  • 5-Physician’s Assistant
  • 6-Obstetrician/Gynecologist (a doctor who sees only women and girls for reproductive health issues)
  • 7-Doctor in an immediate care center
  • 8-I don’t know
  • 9-Other (please describe) ___________________________

9a. How often do you have a checkup?

  • 1-More than once a year
  • 2-About once a year
  • 3-Every two years
  • 4-Every 3-4 years
  • 5-I don’t have checkups anymore

10a. When was your last checkup?

  • 1-In the last year
  • 2-In the last two years
  • 3-In the last 3 or 4 years
  • 4-Over four years ago
  • 5-I don’t remember ever having a checkup

11a. Would you like to have a checkup more often?

  • 1-Yes
  • 2-No

12a. If you would like to have a checkup more often, why haven’t you?
( Check all that apply )

  • 1-No insurance or money to pay for visit
  • 2-No way to get to doctor’s office
  • 3-Don’t know how to get an appointment
  • 4-Don’t feel comfortable with my doctor
  • 5-My parents didn’t think I needed to go
  • 6-No way to go without my parents being
  • involved
  • 7-I don’t want to have a checkup more often
  • 8-Other (please describe) ___________________________

13a. How was your last checkup paid for?

  • 1-Family private insurance
  • 2-Medicaid
  • 3-Our family pays it all/no insurance
  • 4-Don’t know

14a. Who decided it was time for you to have your last checkup?

  • 1-I did
  • 2-Parent/guardian
  • 3-Camp requirement
  • 4-School requirement
  • 5-Sports’ program requirement
  • 6-Job requirement
  • 7-Other (please describe)

15a. Who made your last check-up appointment?

  • 1-I did
  • 2-Parent/guardian
  • 3-Other (please describe) ___________________________

16a. Was your parent/guardian present with you during the entire visit with the doctor?

  • 1-Yes
  • 2-No

16a1. If yes, would you have preferred that you had some time alone with the doctor?

  • 1-Yes
  • 2-No

17a. Were you satisfied with your last checkup?

  • 1-YES
  • 2-No

17a1. Why/why not?

________________________________________________________________

________________________________

18a. If you had a personal problem, would you discuss it with your doctor, nurse practitioner, or physician’s assistant?

Yes No
__ __ 1-Drug/alcohol problem
__ __ 2-Difficulties with parent/family
__ __ 3-Sexuality related issues
__ __ 4-Problem with friend
__ __ 5-Feeling very depressed
__ __ 6-Difficulty in school
__ __ 7-Other (please describe)
Column B

(if you answered NO to question 7)
If you do not have a doctor or other health care provider for checkups:

8b. Would you like to have a doctor, Nurse Practitioner, or Physician’s Assistant for checkups?

  • 1-Yes
  • 2-No

9b. Why don’t you have a doctor to go to for checkups?

  • 1-No insurance or money to pay for visit
  • 2-No way to get to doctor’s office
  • 3-Don’t know how to get an appointment
  • 4-My parents didn’t think I needed to go
  • 5-No way to go without my parents being
  • involved
  • 6-Don’t know any doctors
  • 7-Don’t need checkups
  • 8-Other (please describe) ___________________________

10b. What kind of health care provider would you like to see

  • 1-Family doctor/practitioner
  • 2-Pediatrician (a doctor who sees babies,
  • children and teens)
  • 3-Internist (a doctor who sees only teens & adults)
  • 4-Nurse Practitioner
  • 5-Physician’s Assistant
  • 6-Obstetrician/Gynecologist (a dr. who sees
  • only females for reproductive health issues)
  • 7-Doctor in an immediate care center
  • 8-None–I don’t want to see a doctor
  • 9-Other (please describe) ___________________________

11b. How often would you like to have a checkup?

  • 1-More than once a year
  • 2-About once a year
  • 3-Every two years
  • 4-Every 3-4 years
  • 5-I don’t want to have checkups anymore

12b. When was your last checkup?

  • 1-In the last year
  • 2-In the last two years
  • 3-In the last 3 or 4 years
  • 4-Over four years ago
  • 5-I don’t remember ever having a checkup

13b. In what setting would you like to have the checkup done?

  • 1-Doctor’s office
  • 2-Community clinic
  • 3-School based clinic
  • 4-Immediate care center
  • 5-Emergency room

Dental check-ups: This section is about dental check-ups, which are routine visits to have your teeth cleaned and checked, x-rays may be taken, fluoride treatments may be done, and dental care may be discussed with you.

19. Do you have a dentist or other dental care provider to go to for a check-up?

  • 1-Yes
  • 2-No
Column A

(If you answered YES to question 19)
If you have a dentist or dental care provider for check-ups:

20a. How often do you have a check-up?

  • 1-Twice a year or more
  • 2-About once a year
  • 3-Every 2 years
  • 4-Every 3-4 years

21a. When was your last check-up?

  • 1-In the last year
  • 2-In the last 2 years
  • 3-In the last 3-4 years
  • 4-Over 4 years ago
  • 5-I don’t remember ever having a dental check-up

22a. Would you like to have a dental check-up more often?

  • 1-Yes
  • 2-No

23a. If you would like a check-up more often, why haven’t you?
(Check all that apply)

  • 1-No insurance or money to pay for visit
  • 2-No way to get to dentist’s office
  • 3-Don’t know how to get an appointment
  • 4-My parents didn’t think I needed to go
  • 5-Uncomfortable with my dentist
  • 6-I do not want to have checkups more often
  • 7-Other (please describe) ___________________________

24a. How was your last dental check-up paid for?

  • 1-Family’s dental insurance
  • 2-Medicaid or Dr. Dynasaur
  • 3-My family pays it all/no insurance
  • 4-Don’t know

25a. Who decided it was time for your last dental check-up?

  • 1-I did
  • 2-My parent(s)
  • 3-The dentist sent a notice
Column B

(If you answered NO to question 19)
If you do not have a dentist or dental care provider for check-ups:

20b. If you don’t have a dentist or other dental care provider for regular check-ups–Would you like to have a dentist or dental hygienist for check-ups?

  • 1-Yes
  • 2-No

21b. Why don’t you have a dentist or dental hygienist for checkups?
(Check all that apply)

  • 1-No insurance or money to pay for visit
  • 2-No way to get to dentist’s office
  • 3-Don’t know how to get an appointment
  • 4-My parents didn’t think I needed to go
  • 5-I don’t know any dentists
  • 6-I don’t need checkups
  • 7-Other (please describe) ___________________________

22b. How often would you like to have a check-up?

  • 1-Twice a year
  • 2-Once a year
  • 3-Every 2 years
  • 4-Every 3-4 years
  • 5-I don’t want to have check-ups

Dental Work visits: This next section is about dental work visits, which are visits to see the dentist for a toothache or to have a cavity filled or a tooth repaired.

26. Do you have a dentist to go to when you have a toothache or need your teeth repaired?

  • 1-Yes
  • 2-No

27. Where do you go when you need dental care?

  • 1-I go to my dentist
  • 2-I go to my medical doctor
  • 3-If I can, I go to my dentist; if that’s not possible, I go to the emergency room
  • 4-I don’t go

28. Have you ever wanted to see a dentist about a dental problem (toothache, broken tooth, etc) but were unable to?

  • 1-Yes
  • 2-No

28a. If yes, why? (Check all that apply)

  • 1-No insurance or money to pay for visit
  • 2-No way to get to dentist’s office
  • 3-Don’t know how to get an appointment
  • 4-Don’t feel comfortable with my dentist
  • 5-My parents didn’t think I needed to go
  • 6-Couldn’t find anyone to see me
  • 7-Don’t know any dentists
  • 8-Other (please describe) ___________________________

29. If you had a dental problem or needed dental information but didn’t know where to go, how would you get help? (Check all that apply)

  • 1-Parent
  • 2-Library
  • 3-Teacher
  • 4-Hotline
  • 5-Friend
  • 6-Guidance Counselor
  • 7-Health Teacher
  • 8-School Nurse
  • 9-Phone Book
  • 10-Other (please describe) ________________________

This section is for everyone

30. Are there any health issues that you would like to know more about?

_____________________________________________

_____________________________________________

_____________________________________________

31. Would you be interested in having more health care (including mental health and/or dental) services provided at or very near your school?

  • 1-Yes
  • 2-No

31a. If yes, what services are you interested in?

______________________________________________

______________________________________________

______________________________________________