Follow-up Questionnaire for Parents · Follow-up Questionnaire for Parents ... only a sample of words; ... Housing society or co-operative Tied to occupation Other

Follow-up Questionnaire for ParentsWe would like to ask you some questions about your child’s health and progress. Please tick the most appropriate box against each question, giving further details where requested. If you need more space, please write at the end of the questionnaire, referring to the question by number.

These questions are really important for us to find out how well your child is doing since they left hospital. The answers to these questions together with the assessment that the paediatrician will do will give us a full picture of your child’s progress and health.

First name:

Surname:

Date of birth: / /D M Y YMD

Study number:

NPEU to insert label

here

Version 2 October 2011 ISRCTN00842661 MREC ref.06/MRE04/91 Page 1 of 10

Section A: Your child’s healthA1. Sincecominghomefromhospitalafterbirth,hasyourchildever

receivedoxygenathome? Yes No

IfNo, please go to question A2.IfYes, when did your child last receive oxygen at home?If your baby is still receiving oxygen, please write today’s date / /D M Y YMD

A2. Sincecominghomefromtheneonatalunit,hasyourchildneededtogobackintohospital? Yes No

IfNo, please go to question A4.

A3. Pleasetelluswhenyourchildwasinhospital,howlongtheadmissionlastedandthemainreasonfortheadmission:

Dateadmitted Numberofnightsintotal?

Reasonforadmission(e.g. chest problems)

Didyourchildreceiveintensivecare?

Wasyourchild

ventilated?

Yes No Yes No

/ /D M Y YMD

/ /D M Y YMD

/ /D M Y YMD

/ /D M Y YMD

A4. Isyourchildcurrentlyonanymedicinesforchestproblems? Yes No IfNo,please go to question A5.IfYes, which of the following do they need? (tick all that apply)

Relievers (e.g. ventolin or bricanyl (blue)

Ifticked: only when needed?

OR used everyday?

Preventers (e.g. pulmicort/becotide (brown) or flixotide (yellow)

Steroids (e.g. prednisolone)

Antibiotics

Other

Page 2 of 10 ISRCTN00842661 MREC ref.06/MRE04/91 Version 2 October 2011

A5. Pleasetellusthenamesofanyothermedicationwhichyourchildison:

A6. Doesyourchildsufferfromcoughing? Yes No IfNo,please go to question A7.IfYes, does the cough start with exercise? Yes No Does the cough start with infection? Yes No Please indicate how often:

More than once a week

Once a week or less, but more than once a month

Once a month or less

A7. Doesyourchildsufferfromwheezing? Yes No IfNo,please go to question A8.IfYes, please indicate how often:

More than once a week

Once a week or less, but more than once a month

Once a month or less

A8. HasyourchildbeenseenbyanOphthalmologist,orattendedanEyeExaminationsincetheyweredischargedfromhospital? Yes No

IfYes, please provide details:Ophthalmologist’s Name:

Clinic Address:

Date of last visit: / /D M Y YMD

A9. HasyourchildbeenreviewedbyaPaediatrician,orattendedaChildDevelopmentAssessmentsincetheyweredischargedfromhospital? Yes No

IfYes, please provide details:Paediatrician’s Name:

Clinic Address:

Date of last visit: / /D M Y YMD


Section B: Your child’s behaviourFor each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of your child’s behaviour over the last 6 months.

NotTrue SomewhatTrue

CertainlyTrue

B1. Considerateofotherpeople’sfeelings

B2. Restless,overactive,cannotstaystillforlong

B3. Oftencomplainsofheadaches,stomach-achesorsickness

B4. Sharesreadilywithotherchildren(treats,toys,pencilsetc.)

B5. Oftenhastempertantrumsorhottempers

B6. Rathersolitary,tendstoplayalone

B7. Generallyobedient,usuallydoeswhatadultsrequest

B8. Manyworries,oftenseemsworried

B9. Helpfulifsomeoneishurt,upsetorfeelingill

B10. Constantlyfidgetingorsquirming

B11. Hasatleastonegoodfriend

B12. Oftenfightswithotherchildrenorbulliesthem

B13. Oftenunhappy,down-heartedortearful

B14. Generallylikedbyotherchildren

B15. Easilydistracted,concentrationwanders

B16. Nervousorclingyinnewsituations,easilylosesconfidence

B17. Kindtoyoungerchildren

B18. Oftenargumentativewithadults

B19. Pickedonorbulliedbyotherchildren

B20. Oftenvolunteerstohelpothers(parents,teachers,otherchildren)

B21. Canstopandthinkthingsoutbeforeacting

B22. Canbespitefultoothers

B23. Getsonbetterwithadultsthanwithotherchildren

B24. Manyfears,easilyscared

B25. Seestaskthroughtotheend,goodattentionspan

Doyouhaveanyothercommentsorconcerns?


B26. Overall,doyouthinkyourchildhasdifficultiesinoneormoreofthefollowingareas:emotions,concentration,behaviourorbeingabletogetonwithotherpeople?

No

Yes - minor difficulties

Yes - definite difficulties

Yes - severe difficulties

IfNo, please go to Section C.

IfyouhaveansweredYes, please answer the following questions about these difficulties:

B27. Howlonghavethesedifficultiesbeenpresent? Less than a month

1-5 months

6-12 months

Over a year

B28. Dothedifficultiesupsetordistressyourchild? Not at all

Only a little

Quite a lot

A great deal

B29. Dothedifficultiesinterferewithyourchild’severydaylifeinthefollowingareas?Notatall

Onlyalittle

Quitealot

Agreatdeal

Home Life

Friendships

Learning

Leisure Activities


Section C: What your child can sayChildren understand many more words than they say. We are particularly interested in the words your child says. Please tick the words you have heard your child use. If your child uses a different pronunciation of a word - for example “tend” for “pretend” or “duice” for “juice” - tick it anyway. This is only a sample of words; your child may know many other words not on this list.

Baa baa Cream Cracker Bed Carry Last

Meow Juice Bedroom Chase Tiny

Ouch/ow Meat Settee/sofa Pour Wet

Uh-oh/oh dear Milk Oven/Cooker Finish After

Woof woof Peas Stairs Fit Day

Bear Hat Flag Hug/cuddle Tonight

Bird Necklace Rain Listen Our

Cat Shoe Star Like Them

Dog Sock Swing Pretend This

Duck Chin School Rip/tear Us

Horse Ear Sky Shake Where

Aeroplane Hand Zoo Taste Beside

Boat Leg Friend Gentle Down

Car Pillow Mummy/mum Think Under

Ball Comb Person Wish All

Book Lamp/torch Bye/bye bye All gone Much

Game Plate Hi/hello Cold Could

Sandwich Rubbish No Fast Need to

Fish Tray Shopping Happy Would

Sauce Towel Thank you Hot If

Please continue to Section D overleaf.


Section D: Your child’s understandingD1. Doesyourchildshowhe/sheunderstandsanywordsorsigns? Yes No

IfNo, please go to Section E: Your home and family circumstances.

D2. Doesyourchildevertalkaboutpasteventsorpeoplewhoarenotpresent?For example, a child who saw a carnival last week might later say “carnival”, “clown” or “band”

Often Sometimes Not yet

D3. Doesyourchildevertalkaboutsomethingthatisgoingtohappeninthefuture?For example, saying “choo-choo” or “bus” before you leave the house on a trip, or saying “swing” when you are going to the park.


D4. Doesyourchildtalkaboutobjectsthatarenotpresent,suchasaskingaboutamissingtoynotintheroom,oraskingaboutsomeonenotpresent?


D5. Doesyourchildunderstandifyouaskforsomethingthatisnotintheroom?For example, would he/she go to the bedroom to get a teddy bear when you say “where’s the bear?


D6. Doesyourchildknowwhothingsbelongto?For example, a child might point to Mummy’s shoes and say “Mummy”.


D7. Hasyourchildbeguntoputtogetherwordsyet,suchas“Daddygone”or“doggiebite”?


Ifyouanswered‘notyet’toquestionD7, please go to Section E: Your home and family circumstances.

Ifyouanswered‘sometimes’or‘often’ please continue to answer question D8.


How your child uses words (complete if ‘often’ or ‘sometimes’ given in response to section D)

For EACH PAIR of sentences below - A and B - tick the one that sounds most like the way your child talks at the moment, even if he/she would not say that exact sentence.

If your child is saying sentences even more complicated than the two examples provided, tick B.

D8. (Talking about something happening right now)

A I make tower

B I making tower

D9. (Talking about something that already happened)

A Daddy pick me up

B Daddy picked me up

D10.

A That my truck

B That’s my truck

D11.

A Baby crying

B Baby is crying

D12.

A There a doggie

B There’s a doggie

D13.

A Coffee hot

B That coffee hot

D14.

A I no do it

B I can’t do it

D15.

A I like read stories

B I like to read stories

D16.

A Biscuit Mummy

B Biscuit for Mummy

D17.

A Don’t read book

B Don’t want you read that book

D18.

A Baby want eat

B Baby want to eat

D19.

A Look at me

B Look at me dancing

Section E: Your home and family circumstancesPlease answer as many of these questions as you can to help us to describe the families taking part in this study. This will help us to identify whether family background or individual circumstances affect our findings.

E1. YoureducationWhat is your highest qualification from school or college? None of the below

Vocational qualification, NVQ, or CSE O Level, GCSE, or Scottish Standards

BTEC, A Levels or Scottish Highers Diploma or HND

University degree Postgraduate University degree

Other qualification

IfOther, please describe:


E2. Yourpartner’seducation

Ifnotapplicable (i.e., no partner), please tick box and go to question E3 What is your partner’s highest qualification from school or college? None of the below

Vocational qualification, NVQ, or CSE O Level, GCSE, or Scottish Standards

BTEC, A Levels or Scottish Highers Diploma or HND

University degree Postgraduate University degree

Other qualification

IfOther, please describe

E3. YouremploymentAre you currently in paid employment? Employed

Self-employed Unemployed

Retired Other


E4. Yourpartner’semployment

Ifnotapplicable (i.e., no partner), please tick box and go to question E5 Is your partner currently in paid employment? Employed

Self-employed Unemployed

Retired Other


E5. YourhomeDo you rent or own your accommodation? Owner (mortgage)

Council rented Private rented (furnished)

Private rented (unfurnished) Housing society or co-operative

Tied to occupation Other



Ifthereisanythingelseyouwouldliketosayaboutyourchild,pleaseusethespacebelow.

Couldyoutelluswhocompletedthequestionnaire?

Relationshiptochild:

Ifanyonehelpedyou,pleasetelluswho

Datequestionnairecompleted: / /D M Y YMD

Thankyouforyourhelp

Please return the completed questionnaire in the Freepost envelope provided, or FREEPOST RLSL-SBZK-HTAT, BOOST-II UK Co-ordinating Centre, NPEU (University of Oxford), Old Road Campus,

Headington, Oxford, OX3 7LF

If you have any questions, please contact: BOOST-II UK Study Co-ordinator on: telephone: 01865 289733 or email: [email protected]

Section B Questions 1 – 29 from Strengths and Difficulties Questionnaire; used with permission from Dr R Goodman 1997 Copyright

Section C: PARCA-R

NPEU Clinical Trials UnitNational Perinatal Epidemiology Unit University of Oxford, Old Road Campus, Headington, OXFORD OX3 7LFTel: 01865 289733 Email: [email protected] www.npeu.ox.ac.uk/boost

Documents

Follow-up Questionnaire for Parents · Follow-up Questionnaire for Parents ... only a sample of words; ... Housing society or co-operative Tied to occupation Other