HEALTH SURVEY for seventh-formers
1 (2)
On this form, we ask you to provide information that is significant in terms of your school-age health and well-being. A nurse
will go through the survey with you. The answers are solely for the use of School Health Services.
PERSONAL INFORMATION
Name and class
Telephone number
Guardian
Telephone number
Guardian
Telephone number
HEALTH AND INJURIES
Do you have any chronic illnesses / allergies?
No
Yes, what?
Do you take medication regularly?
No
Yes, what?
Have you suffered an injury in the past 12 months that required a nurse’s
or doctor’s evaluation?
Have you had chickenpox?
No
No
Yes
Yes
Do you wear
A helmet when riding a bicycle
Yes
No
A reflector when it is dark
Yes
No
A life vest when on the water
Yes
No
HEALTH ROUTINES
Daily, I eat
Breakfast
Lunch
Snack
Milk products
Vegetables
Vitamin D supplement
UF / SOTET / 2012: Terveyskysely 7. luokan oppilaille
I go to bed on weekdays
at
I wake up on
weekdays
Dinner
I go to bed on weekends at
at
I brush my teeth
In the morning
In the evening
Never
I use Xylitol products
Daily
Sometimes
Never
FREE TIME
Hobbies
My daily exercise is
Less than 90 minutes
90 minutes or more
My daily screen time (with TV/computer, game consoles/mobile games) is
Less than 2 hours
2 hours or more
Evening meal
I wake up on weekends
at
HEALTH SURVEY for seventh-formers
FRIEND RELATIONSHIPS
Do you have friends ?
Several
One
2 (2)
Do you have an adult with whom you can discuss a wide
range of issues?
Yes
None
No
Have you witnessed bullying?
Have you been bullied or have you bullied others?
SCHOOL
How much time do you spend on homework
each day?
Does something at school give you difficulties?
No
Yes, what?
WELL-BEING
What things about yourself are you happy with?
What is your general mood like?
What kind of things are you worried about?
Do you have worries related your family?
SUBSTANCE USE
Have you been offered cigarettes, snuff, alcohol or drugs?
No
Yes, what?
Have you tried cigarettes or snuff?
No
Yes
Have you tried alcohol?
No
Yes
Have you tried drugs?
No
Yes
UF / SOTET / 2012: Terveyskysely 7. luokan oppilaille
Is there something else on your mind that you would like to discuss during your health examination?
SIGNATURE
Student’s signature
Date
/
/20
__________________________
The form is returned:
School nurse: ______________________ School:_______________________________________
E-mail:
[email protected] Tel.: ___________________________