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bcs_86_pif
YOUTHSCAN U.K.
An Initiative of the International Centre for Child Studies
PARENTAL INTERVIEW FORM
(A MEDICAL AND SOCIAL HISTORY)
STRICTLY CONFIDENTIAL
Director: Professor Neville Butler MD, FRCP, FRCOG, DCH International Centre for Child Studies
PLEASE USE BLOCK CAPITALS

Teenager's Surname

Generic text

Teenager's Forename(s)

Generic text

Sex

Tick one box

1
M
2
F

Teenager's Home Address

Generic text

Telephone

Generic text

Postcode

Generic text

Teenager's N.H.S. Number

NHS number

Date of Birth

Date of birth

Health District

Generic text

Today's date

Generic date

G.P.'s Name

Generic text

G.P.'s Address

Generic text

Name of Interviewer

Generic text

Status

(*delete as applicable)

1
* school nurse
2
health visitor
3
doctor

Status of respondent(s):

(*delete as applicable)

1
* mother figure
2
father figure
3
other, specify
Other
INTRODUCTORY NOTES
First, may we take this opportunity to thank you for carrying out these interviews on behalf of Youthscan. We are grateful to Health and Education Authorities throughout England. Wales and Scotland without whose co-operation this study would not have been possible. It is about current issues concerning the health and welfare of all teenagers and their families.
The Interview
It is hoped that this Form will be completed in an interview with the child's mother. If for any reason the mother is unavailable, please interview the person who can best answer questions about the teenager's health and development. Sometimes the teenager will not be living with his/her own (i.e. natural) mother. In this case the term mother throughout the form should be taken to imply present mother figure and similarly father should be taken to imply present father figure.
In interviewing the mother please assure her at the outset that her answers will be treated in the strictest confidence and that the 16,000 teenagers concerned will not be identified by name. Please ask the questions in the way you consider to be the most appropriate to obtain the information required. If in the light of the mother's response during the interview you feel that a particular question might be best omitted, please feel free to do this although ideally we should like to have all interviews fully completed.
PLEASE ENSURE THAT EVERY QUESTION IS ANSWERED
Each question requires only one answer unless indicated otherwise. Most questions can be answered by ticking the box beside the relevant response. Other questions require a number for the answer.
For all answers requiring text it would be most helpful if you would use BLOCK CAPITALS
THANK YOU FOR YOUR HELP
ENVIRONMENT OF YOUR CHILD

Has your teenager had the same surname since birth?

1
YES
2
NO
3
NOT KNOWN
If NO,
qc_A1 == 2

please give your teenager's full name: at birth

Generic text

please give your teenager's full name: at 10 years

Generic text

What was your teenager's country of birth?

Tick one box

1
England
2
Wales
3
Scotland
4
Northern Ireland
5
Irish Republic
6
Other country (please specify ...)
Other
If born in the United Kingdom please answer 2(a), 2(b) and 2(c)
qc_A2 >= 1 && qc_A2 <= 5

Your home address at time of his/her birth:

Generic text

Name and address of maternity hospital or place where your teenager was born:

Generic text

Your teenagers home address at age 10 years. If same as at birth, please put AS ABOVE

Generic text
If not born in UK answer 2(d)
qc_A2 == 6

Please give the year when he/she first came to live in UK Year of arrival

Generic date

What ethnic group are the study teenager and present parents? Teenager

Please tick one box in column A, B and C.

1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
Other

What ethnic group are the study teenager and present parents? Mother

Please tick one box in column A, B and C.

1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
9
No mother/father figure
Other

What ethnic group are the study teenager and present parents? Father

Please tick one box in column A, B and C.

1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
9
No mother/father figure
Other

Please add any comments felt necessary

Generic text

Where is the teenager's home most of the time?

Tick one box

1
Private household
2
Private boarding school
3
Residential special school
4
A children's home
5
Hospital (long stay)
6
Other place (please describe ...)
Other

At how many addresses has your teenager lived for six months or longer since her/his 10th birthday? ... address(es)

Generic text

What language is usually spoken in your home?

Tick one box

1
English only
2
Mainly English, but also another language
3
Another language with some English
4
Another language without English (please describe other language ...)
Other
A household consists of a group of people who all live at the same address and who are all catered for by the same person, list below all the members of this household. Include the study teenager, the 'present' parents, other children, relatives or lodgers, who are members of this household. Exclude any who are only at home for short periods.
Relationship to the study teenager (eg father, step-brother) or status in the household (eg lodger) Roster cs_qA7_X Generic text Generic text Generic text Date of birth Generic text Generic text Date of birth Generic text Generic text Generic text Date of birth Generic text Date of birth Generic text Generic text Generic text
Study teenager 1 Surname
Study teenager 1 First name(s)
Study teenager 1 Sex
Study teenager 1 Date of Birth
Study teenager 2 Surname
Study teenager 2 First name(s)
Study teenager 2 Sex
Study teenager 2 Date of Birth
Study teenager 3 Surname
Study teenager 3 First name(s)
Study teenager 3 Sex
Study teenager 3 Date of Birth
Study teenager 4 Surname
Study teenager 4 First name(s)
Study teenager 4 Sex
Study teenager 4 Date of Birth
Study teenager 5 Surname
Study teenager 5 First name(s)
Study teenager 5 Sex
Study teenager 5 Date of Birth
Study teenager 6 Surname
Study teenager 6 First name(s)
Study teenager 6 Sex
Study teenager 6 Date of Birth
Study teenager 7 Surname
Study teenager 7 First name(s)
Study teenager 7 Sex
Study teenager 7 Date of Birth
Study teenager 8 Surname
Study teenager 8 First name(s)
Study teenager 8 Sex
Study teenager 8 Date of Birth
If more than 10 please continue on back page
List below any members of the family not included in the above table. Record, those who are only home for holidays or leave, and give your reason for absence. (for example at residential school, or working away.)
Relationship to teenager Surname First name(s) Sex Date of Birth Reason for absence from home
Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text
1
2
3

How many people are there in the household in all? Younger than study teenager

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many people are there in the household in all? Exactly same age as teenager

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many people are there in the household in all? Older but under 21

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many people are there in the household in all? Older and 21 or over

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Younger than study teenager

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Exactly same age as teenager

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Older but under 21

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Older and 21 or over

Answer (a) and (b) and fill in four numbers on each line (if none write 0)

How many

What is the relationship to the teenager of the person now acting as his/her mother?

Tick one box

1
Natural mother
2
Mother by legal adoption
3
Stepmother
4
Foster mother
5
Grandmother
6
Elder sister
7
Cohabitee of father
8
Other mother figure (Please specify ...)
9
No mother figure
Other
If the teenager is not living with his/her natural mother,

when did the natural mother leave?

(If teenager has never lived with natural mother write 1970)

Generic date
If the teenager's present mother is not his/her natural mother,
qc_A9 != 1

when did she take up this responsibility?

Generic date

Since the teenager's birth how many people have acted as his/her mother?

How many

What is the relationship to the teenager of the person now acting as his/her father?

Tick one box

1
Natural father
2
Father by legal adoption
3
Stepfather
4
Foster father
5
Grandfather
6
Elder brother
7
Cohabitee of mother
8
Other father figure (Please specify ...)
9
No father figure
Other
If the teenager is not living with his/her natural father,

when did the natural father leave?

(If teenager has never lived with natural father write 1970)

Generic date
If the teenager's present father is not his/her natural father,
qc_A10 != 1

when did he take up this responsibility?

Generic date

Since the teenager's birth how many people have acted as his/her father?

How many
With how many natural parents was the study teeager living at Birth, at 5, at 10 and at 16 years of age?

Answer a) b) c) or d) and tick one box on each line

-

1 - Both natural parents

2 - Natural mother

3 - Natural father

4 - Neither natural parents

Birth
Five
Ten
Sixteen
If 2, 3 or 4 are ticked at any age, please answer 11(a)-11(h) below, and specify the changed situation and the reason for this change.
qc_A11 == 2 || qc_A11 == 3 || qc_A11 == 4

Who was the teenager living with at birth, five, ten and sixteen years? At birth

Tick one box in Column A and then tick one box in Column B, C, and D

1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other

Who was the teenager living with at birth, five, ten and sixteen years? At 5

Tick one box in Column A and then tick one box in Column B, C, and D

1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other

Who was the teenager living with at birth, five, ten and sixteen years? At 10

Tick one box in Column A and then tick one box in Column B, C, and D

1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other

Who was the teenager living with at birth, five, ten and sixteen years? At 16

Tick one box in Column A and then tick one box in Column B, C, and D

1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other

Reason for any change - birth-5, 5-10, 10-16 Birth-5

Tick one box for Column A then one box for Column B then one box for Column C

1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other

Reason for any change - birth-5, 5-10, 10-16 5-10

Tick one box for Column A then one box for Column B then one box for Column C

1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other

Reason for any change - birth-5, 5-10, 10-16 10-16

Tick one box for Column A then one box for Column B then one box for Column C

1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other
If there has been any significant change(s) since 10 years
qc_A11_b_C >= 1 && qc_A11_b_C <= 6

please specify below:

Long text
(If the absence began less than one year ago answer part (ii) only, and refer to the whole period for which it has lasted. Otherwise, answer part i and then part ii). If more than one absence refer to the most recent.
Else

How often did the child meet the absent natural parent? During the first 6 months of the parent's absence

Tick one box

1
YES, once a week or more
2
YES, two or three times a month
3
YES, once a month
4
YES 3-5 times in all
5
YES 1-2 times in all
6
NEVER
7
Not known
8
Not applicable
9
Absence began less than one year ago

How often did the child meet the absent natural parent? During the last 6 months of the parent's absence

Tick one box

1
YES, once a week
2
YES, two or three times a month
3
YES, once a month
4
YES, 3-5 times in all
5
YES, 1-2 times in all
6
NEVER
7
Not known
If YES, answer 11(e) below.
qc_A11_d_i >= 1 && qc_A11_d_i <= 5

Did the child ever go on holiday/vacation with the absent natural parent? (during the whole period of the absence)

1
YES
2
NO
3
DON'T KNOW
Did the child's natural parents (who are now living apart from each other) discuss with each other the following aspects of the child's life?

Answer (a) (d) and tick one box in each line

-

1 - Never discussed this issue

2 - Only in an emergency or crisis

3 - Routinely discussed this issue

4 - Not known

5 - Not applicable

Child's educational attainment
Child's health
Child's behaviour
Plans for the child's future education, training, employment etc

Does the absent natural parent pay maintenance to the child's custodial parent?

1
YES
2
NO but has in past
3
NO never
4
Not known
5
Not applicable

Has a court ever ordered that maintenance should be paid to the child's custodial parent by the absent natural parent?

1
YES
2
NO
3
Not known
4
Not applicable

Has the teenager ever been subject to any of the following orders:

Tick all that apply

1
Adoption
2
Residential care
3
Supervision order
4
Place of safety order
5
Youth custody
6
Detention centre (Name of above ...)
7
None of above
Generic text

Has anyone ever had to take parental responsibility from the child's natural or adoptive parent(s)?

1
YES
2
NO
3
DON'T KNOW
If YES, answer 13(a), (b), (c), (d), (e), (f), (g)
qc_A13 == 1

How many times has this occurred in all?

Tick one box to indicate number of times

1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10+

How many times has this occurred since the 10th birthday?

Tick one box

0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10+

For the most recent episode, please give the following information: Age of child (years and months) at onset

Age

For the most recent episode, please give the following information: Age (years and months) when ended

Age

Where did he/she stay? (eg fostered, institution, at home, with friends, with relatives, elsewhere) Say where

Generic text

Was a statutory order made?

1
YES, supervisory
2
YES, care
3
NO

What was the reason for the most recent episode?

1
Eviction
2
Desertion
3
Judicial Sentence
4
Illness
5
Other reason (what? ...)
Other
Section B HEALTH

Has the study teenager lost any second teeth?

Tick all that apply

1
NO
2
DON'T KNOW
3
YES, through decay
4
YES, as a procedure for straightening teeth
5
YES, for other reason (please specify ...)
6
YES, reason not known
Other

Has the study teenager been seen by a dentist during the past 12 months?

Tick all that apply

1
NO
2
DON'T KNOW
3
YES but don't know reason
4
YES, for inspection
5
YES, for fillings and/or extractions
6
YES, for straightening teeth
7
YES, other reason (please specify ...)
Other
If YES, please answer 2(a)
qc_B2 >= 3 && qc_B2 <= 7

Was it a

Tick all that apply

1
School dentist?
2
NHS dentist?
3
Dental hospital?
4
Casualty department?
5
Private dentist?

Does the teenager wear a: Dental brace?

1
Yes
2
No

Does the teenager wear a: False tooth (or teeth)?

1
Yes
2
No

Does the teenager wear a: Capped tooth (or teeth)?

1
Yes
2
No

Does the teenager wear a: Hearing aid?

1
Yes
2
No

Has the teenager ever been prescribed spectacles or contact lens? Glasses

For Column A tick one box. Then for Column B tick one box.

1
YES, he/she wears them only for close vision (like reading)
2
YES, he/she wears them only for distant vision
3
YES, he/she wears them all the time
4
YES, but he/she doesn't wear them
5
NO

Has the teenager ever been prescribed spectacles or contact lens? Contact lens

For Column A tick one box. Then for Column B tick one box.

1
YES, he/she wears them only for close vision (like reading)
2
YES, he/she wears them only for distant vision
3
YES, he/she wears them all the time
4
YES, but he/she doesn't wear them
5
NO
If YES, answer 4a, b, c, d
(qc_B4_A >= 1 && qc_B4_A <= 4) || (qc_B4_B >= 1 && qc_B4_B <= 4)

When was he/she prescribed them?

Generic text

How many pairs has he/she had all together?

How many
If he/she doesn't wear them,
qc_B4_A == 4 || qc_B4_B == 4

If he/she doesn't wear them, when did he/she stop?

Generic text

Why did he/she stop?

Generic text

Has the study teenager suffered in the past 12 months from any of the following?

Tick all that apply

1
Hay fever or allergic rhinitis
2
Recurrent vomiting or bilious attacks
3
Dysmenorrhoea (girls only)
4
Travel sickness
5
Recurrent abdominal pain(s)
6
Recurrent throat and/or ear infections requiring treatment by a doctor
7
Acne (other than trivial)
8
Eczematous rashes
9
Psoriasis
10
None of the above
Migraine

Has the study teenager had attacks of migraine or recurrent sick headaches in the past 12 months?

1
NO
2
DON'T KNOW
3
YES, but none in the past month
4
YES, one in the past month
5
YES, more than one in the past month
6
YES, but frequency unknown
If YES,
qc_B6 >= 3 && qc_B6 <= 6

please specify exact nature of attacks:

Generic text
(continue at back of form if necessary)
Psychiatric and Behaviour Problems

Has the study teenager ever been seen by a specialist for an emotional or behaviour problem?

Tick all that apply

1
NO
2
DON'T KNOW
3
YES, as an inpatient in hospital
4
YES, in a hospital outpatient department
5
YES, at a family guidance clinic
6
YES, elsewhere please specify
Other
If YES,
qc_B7 >= 3 && qc_B7 <= 6
please give year of attendance, diagnosis and name and address of hospital/clinic attended:
Year(s) of attendance(s) Diagnosis Name and address of hospital/clinic attended
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4

Has the study teenager ever had any form of fit, convulsion, epileptic attack or other turn in which consciousness was lost, or has any part of the body made abnormal movements (do not include emotional faints)?

1
YES
2
NO
3
DON'T KNOW
If YES, please answer B(a) and (b)
qc_B8 == 1

What was diagnosed?

Generic text

When did the first and most recent episodes occur? First

Tick one box for first and one box for most recent

1
Before 1st birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 10th birthdays
5
Since 10th birthday but not in the past 12 months
6
In past 12 months
7
Don't know age

When did the first and most recent episodes occur? Most recent

Tick one box for first and one box for most recent

1
Before 1st birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 10th birthdays
5
Since 10th birthday but not in the past 12 months
6
In past 12 months
7
Don't know age
If any episode since 10 years, please answer 8(c) below.
If episode(s) have taken place since the age of 10,
qc_B8_b_i == 5 || qc_B8_b_i == 6 || qc_B8_b_ii == 5 || qc_B8_b_ii == 6

please enter details below: Age and nature of attack, type, duration, disposal and treatment

Long text

please enter details below: Name and address of any hospital or specialist attended

Long text

Has the study teenager ever had any attacks of wheezing or whistling in the chest?

1
YES
2
NO
3
DON'T KNOW
If YES, please answer 9(a), 9(b), 9(c), 9(d), 9(e), 9(f)
qc_B9 == 1

Please state when attacks have occurred Before 5 years

Answer a) - c) and tick one box on each line

1
No
2
Yes
If yes,
qc_B9_a_a == 2

How many attacks? give number

How many

Please state when attacks have occurred Between 5 and 10 years

Answer a) - c) and tick one box on each line

1
No
2
Yes
If yes,
qc_B9_a_b == 2

How many attacks? give number

How many

Please state when attacks have occurred Since 10 years

Answer a) - c) and tick one box on each line

1
No
2
Yes
If yes,
qc_B9_a_c == 2

How many attacks? give number

How many

What were these thought to be due to?

Tick all that apply

1
Asthma
2
Wheezy bronchitis
3
Other cause(s) please specify
Other

Have the attack(s) ever necessitated investigation/treatment?

Tick all that apply

1
NO
2
DON'T KNOW
3
YES, admitted to hospital
4
YES, seen by a specialist in an outpatient department/clinic
5
YES, investigated by a GP

When did (A) the first occur and (B) the most recent attack occur? First attack

Tick one box under A and one under B

1
Before first birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 7th birthdays
5
Between 7th and 10th birthdays
6
Since 10th birthday but not in the past 12 months
7
In past 12 months
8
Don't know age

When did (A) the first occur and (B) the most recent attack occur? Most recent

Tick one box under A and one under B

1
Before first birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 7th birthdays
5
Between 7th and 10th birthdays
6
Since 10th birthday but not in the past 12 months
7
In past 12 months
8
Don't know age
If the teenager has had asthma or wheezy bronchitis in the past 12 months,
(qc_B9_b == 1 || qc_B9_b == 2) && (qc_B9_d_A == 7 || qc_B9_d_B == 7)

did this occur

Tick one box

1
At least once a week?
2
Usually less than once a week?
3
Less than once a month?
4
Frequency unknown?

Please describe what medication has been used in the past and/or currently.

Generic text
continue on back pages if necessary

Has the study teenager had bronchitis since his/her 10th birthday?

1
YES
2
NO
3
DON'T KNOW

Has the teenager had any of the following since 10 years?

Tick all that apply

1
German measles
2
Measles
3
Mumps
4
Whooping cough
5
Chicken pox
6
Meningitis
7
Glandular fever
8
None of above
Has the teenager had any operations since 10 years?
Tick all that apply at age ... years

1 - Tick

Age

1 - Tick

Age

1 - Tick

Age

1 - Tick

Age
Tonsillectomy or Ts and As
Hernia operation
Appendiscectomy
Operation for squint
Grommets
Gynaecological procedure (what? ...)

Has the teenager had any operations since 10 years? Gynaecological procedure (what? ...)

Generic text

Has the teenager had any operations since 10 years? No operation since 10 years

1
Tick

Has the study child been admitted to hospital since his/her 10th birthday?

1
YES
2
NO
3
DON'T KNOW
If YES, answer 13(a), 13(b), 13(c).
qc_B13 == 1

Please give total number of admissions since 10th birthday: No:

How many
Please list details of all hospital admissions since 10th birthday:
Age at admission (years) Number of nights in hospital Reason for admission and diagnosis Treatment including operations and other procedures Name and full address of hospital
Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many
1st admission
2nd admission
3rd admission
Continue on back page if more than 3 admissions
Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday.

Tick all that apply in Col 1 and Col 2

Col 1 In-Patient Col 2 Out-Patient

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

Operation
Accident
Asthma/Wheezy bronchitis
Upper respiratory tract infection(s) (including E.N.T. problems)
Chest infections
Urinary tract infections/investigation
Other infections
Convulsions
Heart investigation/treatment
Abdominal conditions not requiring operation
Disorders of bones and joints
Blood disorders including leukaemia/anaemia etc.
Tumours, neoplasms and other malignant conditions
Endocrine disorders (diabetes, thyroid, etc.)
Skin conditions
Eye conditions
Problems of nutrition (e.g. over or underweight etc.)
Emotional conditions (specify ...)
Any other conditions (What? ...)

Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday. Emotional conditions (specify ...)

Generic text

Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday. Any other conditions (What? ...)

Other
Hospital Outpatient Attendances

Since 10 yrs. has the study teenager attended (i) a hospital outpatient department, (ii) a casualty/accident department or (iii) a specialist clinic?

Tick all that apply

1
NO
2
YES, a hospital outpatient department
3
YES, a casualty department
4
YES, a specialist clinic
5
DON'T KNOW
If YES, answer 14(a) below.
qc_B14 == 2 || qc_B14 == 3 || qc_B14 == 4
Please give details of all conditions or illnesses resulting in attendance(s) since his/her 10th birthday:
Age at 1st attendance (years) Total number of attendances Diagnosis and treatment Name and address of department, hospital or clinic
AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text
1st illness
2nd illness
3rd illness
If more than 3 conditions use back page
Accidents

Has the study child had an accident requiring medical advice or treatment since his/her 10th birthday?

(Please include accidents at home, at school, on the road and elsewhere, ingestion of medicines/poisons, burns/scalds.)

1
YES
2
NO
3
DON'T KNOW
If YES,
qc_B15 == 1

Please give total number of accidents since 10th birthday. ... accidents

How many
Please list below details of all accidents since 10th birthday:
Age (years) Where did it happen? (road, home, school, etc.) What happened? Description of 'injuries' (e.g. burn/scald, fracture, head injury with unconsciousness etc) Treatment (including stitches, operation(s) plaster cast(s), traction etc) Where treated (GP, casualty, in-patient)?
AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge
1st accident
2nd accident
3rd accident
(more spaces available at back of this form)
Medical causes of school absence

How much time altogether has the study child missed from school in the past 12 months for reasons of ill-health or emotional disturbance?

Tick one box

1
None, or less than one week in all
2
Over one week and up to one month in all
3
Over one month and up to three weeks in all
4
Over three months in all
5
Missed school, but don't know for how long
6
Don't know whether missed school
7
Does not attend school Please state why:
Generic text
If YES, answer 1(a) below.
qc_C1 >= 2 && qc_C1 <= 5
If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply).
-

1 - Tick

Colds, catarrh, sore throats, ear infections
Bronchitis or chest infections, including pneumonia or influenza
Asthma or wheeziness
Headaches
Bilious attacks or diarrhoea
Dysmenorrhoea
Abdominal pain
Convulsions, fits or turns

If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Emotional or nervous problems (What? ...)

1
Tick
Generic text

If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Infectious diseases (What? ...)

1
Tick
Generic text

If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Accident or injury (Please specify: ...)

1
Tick
Generic text

If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Other cause(s) (What? ...)

1
Tick
Other
Other 2

Has this teenager used any of the following services since 10 years of age? Child/family guidance service, child psychiatrist or educational psychologist

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known

Has this teenager used any of the following services since 10 years of age? General practioner service for: a check up

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known

Has this teenager used any of the following services since 10 years of age? General practioner service for: immunisation (what against ...)

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text

Has this teenager used any of the following services since 10 years of age? General practioner service for: injury/illness (what? ...)

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text

Has this teenager used any of the following services since 10 years of age? Dental hygienist

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known

Has this teenager used any of the following services since 10 years of age? Speech therapist (what for? ...)

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text

Has this teenager used any of the following services since 10 years of age? Health visitor

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known

Has this teenager used any of the following services since 10 years of age? Other service(s) used (What? ...)

Answer each one and tick all that apply

1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Other
Has this teenager, your husband or yourself been to any of the following in the past 12 months?

Tick all that apply

(Why? ...) -

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text
Acupuncturist
Homeopath
Faith healer
Osteopath/chiropractor
Hypnotist

Has this teenager, your husband or yourself been to any of the following in the past 12 months? Other "alternative medical helper" (Who? ...)

Tick all that apply

1
My Teenager
2
My Husband
3
Other Member of family
4
Myself
Other
Private Medical Care
During the last 12 months, which if any of the family has been treated on a private basis by a qualified medical doctor?

Answer (a)-(c) and tick one box on each line.

-

1 - No

2 - Don't know

3 - Yes & privately insured

4 - Yes but not privately insured

My teenager
My husband
Myself
If YES, answer 3(a) below.
qc_D3_a-c == 3 || qc_D3_a-c == 4

What was the condition/illness? Study teenager

Generic text

What was the condition/illness? My husband

Generic text

What was the condition/illness? Myself

Generic text
Please enquire or state from your own knowledge if (a) the study teenager, and (b) any other member of the family, has had any contact with any of the following services since the study child's 10th birthday?

Tick all that apply separately for A and B

A Teenager B Other member(s) of the family

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

Social Services or Social Work Department (including former Children's Department)
Educational Welfare Department
Careers Officer/Youth Employment Officer
Voluntary Social Work Agency (Please state which: ...)
Police
Probation Office

Please enquire or state from your own knowledge if (a) the study teenager, and (b) any other member of the family, has had any contact with any of the following services since the study child's 10th birthday? Voluntary Social Work Agency (Please state which: ...)

Generic text
If there has been any such contact,
qc_D4_i == 1

please state why and who arranged the contact in the first instance:

Generic text
(more space available at back of this form)

Has the study teenager ever been taken to court (or children's hearing in Scotland) to your knowledge?

1
YES
2
NO
3
DON'T KNOW
If YES,
qc_D5 == 1

please give as many details as you can:

Generic text
Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) TEENAGER
Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5
Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) MY HUSBAND
Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5
Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) MYSELF
Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5

Does your teenager have an impairment, a disability or a handicap? (By 'Impairment' we mean a physical or mental abnormality/illness. By 'Disability' we mean difficulty in doing one or more mental or physical activities that average 16 year olds can do. By 'Handicap' we mean a disability which interferes with the opportunities that others take for granted, e.g. problems with access/facilities in public buildings; not being considered for jobs he or she could manage if given a chance; other people are put off without even knowing what he or she is like.)

Tick all that apply

1
NO
2
YES, an impairment
3
YES, a disability
4
YES, a handicap
5
NOT KNOWN
If YES, please answer 7(a) below.
qc_D7 == 2 || qc_D7 == 3 || qc_D7 == 4

Please describe his or her condition:

Long text
Section E: FAMILY FINANCES
Please explain that knowledge of the economic circumstances of families with teenage children is vital in this study of the development of teenagers in Britain.

What have been the source(s) of income of the household during the past 12 months?

Tick all that apply, but exclude study teenager's earnings, if any)

1
Father's employment
2
Mother's employment
3
Brother's/sister's employment
4
Other adult member(s) of household's employment
5
Investments and/or private income
6
Annuities and pensions (other than Social Security)
7
Supplementary Benefit
8
Unemployment Benefit
9
Widow's Pension/Widowed mother's allowance
10
Sickness Benefit
11
One-parent Benefit
12
Housing Benefit
13
Mobility Allowance
14
Rent or Rates Rebate
15
Retirement Pension
16
Disability Pension
17
Attendance Allowance
18
Family Income Supplement
19
Any other source(s) (Please specify: ...)
Other
Combined Income of present parents

Please show the following table of incomes to the respondent and ask her to mark the income band which is appropriate. The figures refer to the COMBINED GROSS INCOME OF THE CHILD'S MOTHER AND FATHER. (Do not include Child Benefit, but include all other earned and unearned income before deductions for tax, national insurance, etc) Enter either as weekly or yearly sum WEEKLY INCOME

Tick one box

1
Less than £50
2
£50 - £99
3
£100 - £149
4
£150 - £199
5
£200 - £249
6
£250 - £299
7
£300 - £349
8
£350 £399
9
£400 - £449
10
£450 - £499
11
£500 and over
12
REFUSE TO ANSWER
13
UNCERTAIN

Please show the following table of incomes to the respondent and ask her to mark the income band which is appropriate. The figures refer to the COMBINED GROSS INCOME OF THE CHILD'S MOTHER AND FATHER. (Do not include Child Benefit, but include all other earned and unearned income before deductions for tax, national insurance, etc ) Enter either as weekly or yearly sum YEARLY INCOME

Tick one box

1
Less than £2600
2
£2600 - £5199
3
£5200 - £7799
4
£7800 - £10399
5
£10400 - £12999
6
£13000 - £15599
7
£15600 - £18199
8
£18200 - £20799
9
£20800 - £23399
10
£23400 - £25999
11
£26000 and over
12
REFUSE TO ANSWER
13
UNCERTAIN
Family Expenditure
How much money is spent each week/month by your household on the following goods, and how many people share the goods? (It is realised that this will be an estimate and very approximate.)

Answer (a)-(f) On each line, answer A or B, and C. If don't know, write DK.

A Weekly Expenditure £ OR B Monthly Expenditure £ C Number of people sharing goods
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
Food and household sundries
Alcohol
Tobacco
Clothing
Travel
Entertainment

Have you, as a family, been seriously troubled by financial hardship in the past 12 months?

1
YES
2
NO
3
Uncertain
4
Don't know
5
Other reply (What? ...)
Other
If YES, please answer 4(a).
qc_E4 == 1

Please can you give us any details?

Generic text
Section F: ACCOMMODATION

What accommodation do you occupy?

Tick one box

1
House or bungalow occupied by us
2
Flat or maisonette with our own front door
3
Flat or rooms in building shared with other households (i.e. not self-contained)
4
Mobile home, houseboat, caravan or tent
5
Other type of accommodation (What? ...)
Other
If House or Bungalow, answer 1(a).
qc_F1 == 1

Is the house or bungalow.

Tick one box

1
Detached?
2
Semi-detached?
3
Terraced (including end of terrace)?
If Flat, maisonette or rooms, anwser 1(b) below.
qc_F1 == 2

Please give the lowest floor on which living room(s) or bedroom(s) are situated:

Tick one box

1
Basement
2
Ground
3
Above ground (give floor ...)
Floor

When was your present accommodation built?

Tick one box

1
In past 10 years
2
Between 10 and 25 years ago
3
Between 25 and 40 years ago
4
1914-1945
5
Pre-1914
6
Don't know

Is your accommodation owned/rented by you? It is

Tick all that apply

1
Owned outright
2
Being bought on mortgage or loan
3
Rented from local authority/council
4
Privately rented (unfurnished)
5
Privately rented (furnished)
6
Tied to occupation of a household member
7
Other situation (What? ...)
Other
If YES, if owned outright/being bought/rented from Local Authority answer 3(a) below.
qc_F3 == 1 || qc_F3 == 2 || qc_F3 == 3

Could you/did you buy as a sitting tenant of the Council?

Tick one box

1
YES
2
NO
3
DON'T KNOW
How many rooms are there within your accommodation? (Do not count kitchen, bathroom or toilets, or any room used solely for business or trade purposes.)

Tick one box

-

0 - 0

1 - 1

2 - 2

3 - 3

4 - 4

5 - 5

6 - 6

7 - 7

8 - 8

9 - 9+

Number of bedrooms
Number of other rooms

Have you the use of the following? Bathroom

Answer (a)-(d) and tick one box on each line

1
Sole Use
2
Shared Use
3
Lack this amenity

Have you the use of the following? Indoor lavatory

Answer (a)-(d) and tick one box on each line

1
Sole Use
2
Shared Use
3
Lack this amenity

Have you the use of the following? Hot water supply

Answer (a)-(d) and tick one box on each line

1
Sole Use
2
Shared Use
3
Lack this amenity

Have you the use of the following? Garden/yard

Answer (a)-(d) and tick one box on each line

1
Sole Use
2
Shared Use
3
Lack this amenity

Please describe the kitchen. Which of the following applies?

Tick one box

1
Kitchen less than 6 feet wide and not used as a living room
2
Kitchen less than 6 feet wide and used as a living room
3
Kitchen 6 feet or more wide and not used as a living room
4
Kitchen 6 feet or more wide and used as a living room
5
No kitchen
6
Don't know

What methods of heating are regularly used at home in the winter and which of these do you use most often? Tick all that apply

1
Central heating: Oil
2
Central heating: Gas
3
Central heating: Electric (night storage)
4
Central heating: Other electric heating
5
Central heating: Solid fuel
6
Central heating: Communal supply
7
Other type of heating: Gas (bottled) paraffin
8
Other type of heating: Gas fires
9
Other type of heating: Oil-filled radiators
10
Other type of heating: Solid fuel
11
Other type of heating: Other heating (What ...)
12
No method of heating
Other

What methods of heating are regularly used at home in the winter and which of these do you use most often? Tick the one you use most often

Other
1
Central heating: Oil
2
Central heating: Gas
3
Central heating: Electric (night storage)
4
Central heating: Other electric heating
5
Central heating: Solid fuel
6
Central heating: Communal supply
7
Other type of heating: Gas (bottled) paraffin
8
Other type of heating: Gas fires
9
Other type of heating: Oil-filled radiators
10
Other type of heating: Solid fuel
11
Other type of heating: Other heating (What ...)
12
No method of heating

How much of your home is heated regularly in winter?

Tick one box

1
All
2
More than half
3
Half
4
Less than half
5
None

How many other people share the same bedroom as the study teenager? (If teenager has own bedroom, tick 0)

Tick one box only

0
0
1
1
2
2
3
3+

How many people sleep in the same bed as the study teenager? (If teenager has own bed, tick 0)

Tick one box only

0
0
1
1
2
2
3
3+
Does your teenager, your husband or yourself have a cough and do any of you spit up phlegm?

Answer (a)-(d) for teenager and tick one box per line Then repeat for Husband Then repeat for Self

In early morning on waking: Cough In early morning on waking: Phlegm During day/night: Cough During day/night: Phlegm

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

MY TEENAGER
MY HUSBAND
MYSELF
Section G: FAMILY HEALTH

Since the teenager's tenth birthday has anyone in the household had any severe or prolonged illness (medical, surgical or psychiatric) or any handicap or disability? Please include illness in mother, father, other adults and children in household; exclude study teenager).

Tick all that apply

1
YES, mother
2
YES, father
3
YES, other adult or child (exclude study teenager)
4
NO, no one in the household has been ill
5
DON'T KNOW
If YES, please answer 1(a).
qc_G1 == 1 || qc_G1 == 2 || qc_G1 == 3
_person < 4 _person < 4

Relationship to the teenager

Generic text

Year of onset

Generic date

Diagnosis or nature of the condition

Generic text

Duration of condition and months

Generic text

Outcome (e.g. recovered, died, condition still present)

Generic text

In what way, if any, has the condition caused any interference with the teenager's everyday life?

Generic text
If more than three people affected, please continue on back page.
As far as you know, does your teenager smoke cigarettes and do you and your husband smoke? Cigarette smoking is defined as one or more cigarettes daily on average.

Tick one box under teenager, husband and self

-

1 - Yes, cigarettes

2 - Smokes cigars/cheroots/pipe

3 - Not sure but probably smokes cigarettes

4 - No, non-smoker always

5 - No, non-smoker now, but smoked in past

My Teenager
My Husband
Myself
If a smoker now: Answer 2(a) and 2(b) for teenager, husband and self
qc_G2$1;1 == 1 || qc_G2$1;1 == 2 || qc_G2$1;1 == 3

How many cigarettes a day on average are smoked? My Teenager ... cigs

How many

At what age did smoking commence? My Teenager ... yrs

Age
If a smoker now: Answer 2(a) and 2(b) for teenager, husband and self
qc_G2$1;2 == 1 || qc_G2$1;2 == 2 || qc_G2$1;2 == 3

How many cigarettes a day on average are smoked? My Husband ... cigs

How many

At what age did smoking commence? My Husband ... yrs

Age
If a smoker now: Answer 2(a) and 2(b) for teenager, husband and self
qc_G2$1;3 == 1 || qc_G2$1;3 == 2 || qc_G2$1;3 == 3

How many cigarettes a day on average are smoked? Myself ... cigs

How many

At what age did smoking commence? Myself ... yrs

Age
If you are an ex-smoker now: Answer 2(c) and 2(d) for teenager, husband and self
qc_G2$1;3 == 4 || qc_G2$1;3 == 5

At what age was smoking last given up? My Teenager ... yrs

Age

At what age was smoking last given up? My Husband ... yrs

Age

At what age was smoking last given up? Myself ... yrs

Age

How many cigarettes a day smoked just before gave up My Teenager ... cigs

How many

How many cigarettes a day smoked just before gave up My Husband ... cigs

How many

How many cigarettes a day smoked just before gave up Myself ... cigs

How many

Will the interviewer during the course of the home visit please make the following three confidential assessments? Tidiness of home The home appears to be:-

Tick one box

1
Over tidy
2
Very tidy
3
Average
4
Untidy
5
Chaotic
6
Can't assess

Will the interviewer during the course of the home visit please make the following three confidential assessments? Furniture/equipment in home The home appears to be:-

Tick one box

1
Luxurious
2
Well equipped
3
Adequate
4
Low standard
5
Very low standard
6
Can't assess

Will the interviewer during the course of the home visit please make the following three confidential assessments? Relationship of family with neighbours This family and the neighbours seem to be on

Tick one box

1
Very good terms
2
Good terms
3
Satisfactory terms
4
Don't mix well
5
Bad terms
6
Can't assess
Section H: NEIGHBOURHOOD

In order to get some impression of the kind of district the teenager lives in, please mark which one of the following descriptions best characterised the neighbourhood.

1
In this district, houses are closely packed together and are in a poor state of repair. Multi-occupation is a common feature, and most families have low incomes
2
This district consists largely of council houses and flats or less expensive privately-owned houses, for example, older terrace houses. Multi-occupation is unusual and families have average incomes. Include 'New Towns' here
3
In this district houses are well spaced and the majority are well maintained. Multi-occupation is rare and most families have average incomes. Include 'New Towns' here
4
This district is part of a small market town, rural community or village. Some families may lack basic ammenities but others may be fairly well-to-do. It is mainly characterised by the fact that the well-to-do and poorer families live close together in the community: This community could be: A rurual area with hardly any other houses nearby and some distance from any town or village
5
This district is part of a small market town, rural community or village. Some families may lack basic ammenities but others may be fairly well-to-do. It is mainly characterised by the fact that the well-to-do and poorer families live close together in the community: This community could be: A country neighbourhood, but in or close to a village
If none of these descriptions seem to characterise the district the teenager lives in,
qc_H1 != 1 && qc_H1 != 2 && qc_H1 != 3 && qc_H1 != 4 && qc_H1 != 5

please describe in your own words what it is like

Generic text
Section J: ASSESSMENT

PLEASE GIVE YOUR OWN ASSESSMENT OF THE TEENAGER'S HEALTH, DEVELOPMENT, PROGRESS AND ALSO THE SOCIAL AND FAMILY BACKGROUND, INCLUDING WHERE POSSIBLE A COMMENT ON FAMILY ATTITUDES AND EXPECTATIONS.

Long text

PLEASE ENTER BELOW ANY FURTHER DETAILS ABOUT HOUSEHOLD MEMBERS, ACCIDENTS, HOSPITAL ADMISSIONS, OUTPATIENT ATTENDANCES, CHRONIC FAMILY ILLNESSES ETC. FOR WHICH THERE WAS INSUFFICIENT SPACE IN THE FORM.

Long text

PLEASE ENTER BELOW ANY COMMENTS OR INFORMATION YOU FEEL ARE RELEVANT.

Long text
IMPORTANT It may be helpful for the doctors on the survey to consult in confidence medical records about a child's admission(s) to hospital or attendance(s) at outpatients or illnesses treated by the family doctor. Would you please ask the parent for her/his permission to do this should it prove necessary now or at a later date.

*I am willing/I am not willing for medical records about my child's illnesses to be consulted if it should prove necessary (*delete as applicable)

1
I am willing
2
I am not willing
PLEASE THANK THE PARENT(S) FOR HER/HIS HELP
End

bcs_86_pif

YOUTHSCAN U.K.
An Initiative of the International Centre for Child Studies
PARENTAL INTERVIEW FORM
(A MEDICAL AND SOCIAL HISTORY)
STRICTLY CONFIDENTIAL
Director: Professor Neville Butler MD, FRCP, FRCOG, DCH International Centre for Child Studies
PLEASE USE BLOCK CAPITALS
Teenager's Surname
Generic text
Teenager's Forename(s)
Generic text
Sex
1
M
2
F
Teenager's Home Address
Generic text
Telephone
Generic text
Postcode
Generic text
Teenager's N.H.S. Number
NHS number
Date of Birth
Date of birth
Health District
Generic text
Today's date
Generic date
G.P.'s Name
Generic text
G.P.'s Address
Generic text
Name of Interviewer
Generic text
Status
1
* school nurse
2
health visitor
3
doctor
Status of respondent(s):
1
* mother figure
2
father figure
3
other, specify
Other
INTRODUCTORY NOTES
First, may we take this opportunity to thank you for carrying out these interviews on behalf of Youthscan. We are grateful to Health and Education Authorities throughout England. Wales and Scotland without whose co-operation this study would not have been possible. It is about current issues concerning the health and welfare of all teenagers and their families.
The Interview
It is hoped that this Form will be completed in an interview with the child's mother. If for any reason the mother is unavailable, please interview the person who can best answer questions about the teenager's health and development. Sometimes the teenager will not be living with his/her own (i.e. natural) mother. In this case the term mother throughout the form should be taken to imply present mother figure and similarly father should be taken to imply present father figure.
In interviewing the mother please assure her at the outset that her answers will be treated in the strictest confidence and that the 16,000 teenagers concerned will not be identified by name. Please ask the questions in the way you consider to be the most appropriate to obtain the information required. If in the light of the mother's response during the interview you feel that a particular question might be best omitted, please feel free to do this although ideally we should like to have all interviews fully completed.
PLEASE ENSURE THAT EVERY QUESTION IS ANSWERED
Each question requires only one answer unless indicated otherwise. Most questions can be answered by ticking the box beside the relevant response. Other questions require a number for the answer.
For all answers requiring text it would be most helpful if you would use BLOCK CAPITALS
THANK YOU FOR YOUR HELP

ENVIRONMENT OF YOUR CHILD

Has your teenager had the same surname since birth?
1
YES
2
NO
3
NOT KNOWN
please give your teenager's full name: at birth
Generic text
please give your teenager's full name: at 10 years
Generic text
What was your teenager's country of birth?
1
England
2
Wales
3
Scotland
4
Northern Ireland
5
Irish Republic
6
Other country (please specify ...)
Other
Your home address at time of his/her birth:
Generic text
Name and address of maternity hospital or place where your teenager was born:
Generic text
Your teenagers home address at age 10 years. If same as at birth, please put AS ABOVE
Generic text
Please give the year when he/she first came to live in UK Year of arrival
Generic date
What ethnic group are the study teenager and present parents? Teenager
1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
Other
What ethnic group are the study teenager and present parents? Mother
1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
9
No mother/father figure
Other
What ethnic group are the study teenager and present parents? Father
1
English, Welsh, Scottish, N. Irish
2
Irish
3
Other European
4
West Indian or Guyanese
5
Indian
6
Pakistani
7
Bangladeshi
8
Mixed parentage or any other ethnic group (please describe ...)
9
No mother/father figure
Other
Please add any comments felt necessary
Generic text
Where is the teenager's home most of the time?
1
Private household
2
Private boarding school
3
Residential special school
4
A children's home
5
Hospital (long stay)
6
Other place (please describe ...)
Other
At how many addresses has your teenager lived for six months or longer since her/his 10th birthday? ... address(es)
Generic text
What language is usually spoken in your home?
1
English only
2
Mainly English, but also another language
3
Another language with some English
4
Another language without English (please describe other language ...)
Other

A household consists of a group of people who all live at the same address and who are all catered for by the same person, list below all the members of this household. Include the study teenager, the 'present' parents, other children, relatives or lodgers, who are members of this household. Exclude any who are only at home for short periods.

Relationship to the study teenager (eg father, step-brother) or status in the household (eg lodger) Roster cs_qA7_X Generic text Generic text Generic text Date of birth Generic text Generic text Date of birth Generic text Generic text Generic text Date of birth Generic text Date of birth Generic text Generic text Generic text
Study teenager 1 Surname
Study teenager 1 First name(s)
Study teenager 1 Sex
Study teenager 1 Date of Birth
Study teenager 2 Surname
Study teenager 2 First name(s)
Study teenager 2 Sex
Study teenager 2 Date of Birth
Study teenager 3 Surname
Study teenager 3 First name(s)
Study teenager 3 Sex
Study teenager 3 Date of Birth
Study teenager 4 Surname
Study teenager 4 First name(s)
Study teenager 4 Sex
Study teenager 4 Date of Birth
Study teenager 5 Surname
Study teenager 5 First name(s)
Study teenager 5 Sex
Study teenager 5 Date of Birth
Study teenager 6 Surname
Study teenager 6 First name(s)
Study teenager 6 Sex
Study teenager 6 Date of Birth
Study teenager 7 Surname
Study teenager 7 First name(s)
Study teenager 7 Sex
Study teenager 7 Date of Birth
Study teenager 8 Surname
Study teenager 8 First name(s)
Study teenager 8 Sex
Study teenager 8 Date of Birth
If more than 10 please continue on back page

List below any members of the family not included in the above table. Record, those who are only home for holidays or leave, and give your reason for absence. (for example at residential school, or working away.)

Relationship to teenager Surname First name(s) Sex Date of Birth Reason for absence from home
Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textDate of birthGeneric textGeneric textGeneric textDate of birthGeneric textGeneric text
1
2
3
How many people are there in the household in all? Younger than study teenager
How many
How many people are there in the household in all? Exactly same age as teenager
How many
How many people are there in the household in all? Older but under 21
How many
How many people are there in the household in all? Older and 21 or over
How many
How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Younger than study teenager
How many
How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Exactly same age as teenager
How many
How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Older but under 21
How many
How many are blood brothers and sisters of the study teenager (or half-brothers/sisters)? Older and 21 or over
How many
What is the relationship to the teenager of the person now acting as his/her mother?
1
Natural mother
2
Mother by legal adoption
3
Stepmother
4
Foster mother
5
Grandmother
6
Elder sister
7
Cohabitee of father
8
Other mother figure (Please specify ...)
9
No mother figure
Other
when did the natural mother leave?
Generic date
when did she take up this responsibility?
Generic date
Since the teenager's birth how many people have acted as his/her mother?
How many
What is the relationship to the teenager of the person now acting as his/her father?
1
Natural father
2
Father by legal adoption
3
Stepfather
4
Foster father
5
Grandfather
6
Elder brother
7
Cohabitee of mother
8
Other father figure (Please specify ...)
9
No father figure
Other
when did the natural father leave?
Generic date
when did he take up this responsibility?
Generic date
Since the teenager's birth how many people have acted as his/her father?
How many

With how many natural parents was the study teeager living at Birth, at 5, at 10 and at 16 years of age?

-

1 - Both natural parents

2 - Natural mother

3 - Natural father

4 - Neither natural parents

Birth
Five
Ten
Sixteen
Who was the teenager living with at birth, five, ten and sixteen years? At birth
1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other
Who was the teenager living with at birth, five, ten and sixteen years? At 5
1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other
Who was the teenager living with at birth, five, ten and sixteen years? At 10
1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other
Who was the teenager living with at birth, five, ten and sixteen years? At 16
1
Natural mother and step-father/natural father and step-mother
2
Natural mother and cohabitee/natural father and cohabitee
3
Mother and relative/father and relative
4
Mother alone/father alone
5
Other situation(s) (What? ...)
Other
Reason for any change - birth-5, 5-10, 10-16 Birth-5
1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other
Reason for any change - birth-5, 5-10, 10-16 5-10
1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other
Reason for any change - birth-5, 5-10, 10-16 10-16
1
Death of mother (or mother figure)
2
Death of father (or father figure)
3
Death of both mother and father
4
Separation of parents
5
Divorce of parents
6
Other situation (what ...)
Other
please specify below:
Long text
How often did the child meet the absent natural parent? During the first 6 months of the parent's absence
1
YES, once a week or more
2
YES, two or three times a month
3
YES, once a month
4
YES 3-5 times in all
5
YES 1-2 times in all
6
NEVER
7
Not known
8
Not applicable
9
Absence began less than one year ago
How often did the child meet the absent natural parent? During the last 6 months of the parent's absence
1
YES, once a week
2
YES, two or three times a month
3
YES, once a month
4
YES, 3-5 times in all
5
YES, 1-2 times in all
6
NEVER
7
Not known
Did the child ever go on holiday/vacation with the absent natural parent? (during the whole period of the absence)
1
YES
2
NO
3
DON'T KNOW

Did the child's natural parents (who are now living apart from each other) discuss with each other the following aspects of the child's life?

-

1 - Never discussed this issue

2 - Only in an emergency or crisis

3 - Routinely discussed this issue

4 - Not known

5 - Not applicable

Child's educational attainment
Child's health
Child's behaviour
Plans for the child's future education, training, employment etc
Does the absent natural parent pay maintenance to the child's custodial parent?
1
YES
2
NO but has in past
3
NO never
4
Not known
5
Not applicable
Has a court ever ordered that maintenance should be paid to the child's custodial parent by the absent natural parent?
1
YES
2
NO
3
Not known
4
Not applicable
Has the teenager ever been subject to any of the following orders:
1
Adoption
2
Residential care
3
Supervision order
4
Place of safety order
5
Youth custody
6
Detention centre (Name of above ...)
7
None of above
Generic text
Has anyone ever had to take parental responsibility from the child's natural or adoptive parent(s)?
1
YES
2
NO
3
DON'T KNOW
How many times has this occurred in all?
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10+
How many times has this occurred since the 10th birthday?
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10+
For the most recent episode, please give the following information: Age of child (years and months) at onset
Age
For the most recent episode, please give the following information: Age (years and months) when ended
Age
Where did he/she stay? (eg fostered, institution, at home, with friends, with relatives, elsewhere) Say where
Generic text
Was a statutory order made?
1
YES, supervisory
2
YES, care
3
NO
What was the reason for the most recent episode?
1
Eviction
2
Desertion
3
Judicial Sentence
4
Illness
5
Other reason (what? ...)
Other

Section B HEALTH

Has the study teenager lost any second teeth?
1
NO
2
DON'T KNOW
3
YES, through decay
4
YES, as a procedure for straightening teeth
5
YES, for other reason (please specify ...)
6
YES, reason not known
Other
Has the study teenager been seen by a dentist during the past 12 months?
1
NO
2
DON'T KNOW
3
YES but don't know reason
4
YES, for inspection
5
YES, for fillings and/or extractions
6
YES, for straightening teeth
7
YES, other reason (please specify ...)
Other
Was it a
1
School dentist?
2
NHS dentist?
3
Dental hospital?
4
Casualty department?
5
Private dentist?
Does the teenager wear a: Dental brace?
1
Yes
2
No
Does the teenager wear a: False tooth (or teeth)?
1
Yes
2
No
Does the teenager wear a: Capped tooth (or teeth)?
1
Yes
2
No
Does the teenager wear a: Hearing aid?
1
Yes
2
No
Has the teenager ever been prescribed spectacles or contact lens? Glasses
1
YES, he/she wears them only for close vision (like reading)
2
YES, he/she wears them only for distant vision
3
YES, he/she wears them all the time
4
YES, but he/she doesn't wear them
5
NO
Has the teenager ever been prescribed spectacles or contact lens? Contact lens
1
YES, he/she wears them only for close vision (like reading)
2
YES, he/she wears them only for distant vision
3
YES, he/she wears them all the time
4
YES, but he/she doesn't wear them
5
NO
When was he/she prescribed them?
Generic text
How many pairs has he/she had all together?
How many
If he/she doesn't wear them, when did he/she stop?
Generic text
Why did he/she stop?
Generic text
Has the study teenager suffered in the past 12 months from any of the following?
1
Hay fever or allergic rhinitis
2
Recurrent vomiting or bilious attacks
3
Dysmenorrhoea (girls only)
4
Travel sickness
5
Recurrent abdominal pain(s)
6
Recurrent throat and/or ear infections requiring treatment by a doctor
7
Acne (other than trivial)
8
Eczematous rashes
9
Psoriasis
10
None of the above

Migraine

Has the study teenager had attacks of migraine or recurrent sick headaches in the past 12 months?
1
NO
2
DON'T KNOW
3
YES, but none in the past month
4
YES, one in the past month
5
YES, more than one in the past month
6
YES, but frequency unknown
please specify exact nature of attacks:
Generic text
(continue at back of form if necessary)
Psychiatric and Behaviour Problems
Has the study teenager ever been seen by a specialist for an emotional or behaviour problem?
1
NO
2
DON'T KNOW
3
YES, as an inpatient in hospital
4
YES, in a hospital outpatient department
5
YES, at a family guidance clinic
6
YES, elsewhere please specify
Other

please give year of attendance, diagnosis and name and address of hospital/clinic attended:

Year(s) of attendance(s) Diagnosis Name and address of hospital/clinic attended
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
Has the study teenager ever had any form of fit, convulsion, epileptic attack or other turn in which consciousness was lost, or has any part of the body made abnormal movements (do not include emotional faints)?
1
YES
2
NO
3
DON'T KNOW
What was diagnosed?
Generic text
When did the first and most recent episodes occur? First
1
Before 1st birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 10th birthdays
5
Since 10th birthday but not in the past 12 months
6
In past 12 months
7
Don't know age
When did the first and most recent episodes occur? Most recent
1
Before 1st birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 10th birthdays
5
Since 10th birthday but not in the past 12 months
6
In past 12 months
7
Don't know age
If any episode since 10 years, please answer 8(c) below.
please enter details below: Age and nature of attack, type, duration, disposal and treatment
Long text
please enter details below: Name and address of any hospital or specialist attended
Long text
Has the study teenager ever had any attacks of wheezing or whistling in the chest?
1
YES
2
NO
3
DON'T KNOW
Please state when attacks have occurred Before 5 years
1
No
2
Yes
How many attacks? give number
How many
Please state when attacks have occurred Between 5 and 10 years
1
No
2
Yes
How many attacks? give number
How many
Please state when attacks have occurred Since 10 years
1
No
2
Yes
How many attacks? give number
How many
What were these thought to be due to?
1
Asthma
2
Wheezy bronchitis
3
Other cause(s) please specify
Other
Have the attack(s) ever necessitated investigation/treatment?
1
NO
2
DON'T KNOW
3
YES, admitted to hospital
4
YES, seen by a specialist in an outpatient department/clinic
5
YES, investigated by a GP
When did (A) the first occur and (B) the most recent attack occur? First attack
1
Before first birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 7th birthdays
5
Between 7th and 10th birthdays
6
Since 10th birthday but not in the past 12 months
7
In past 12 months
8
Don't know age
When did (A) the first occur and (B) the most recent attack occur? Most recent
1
Before first birthday
2
Between 1st and 2nd birthdays
3
Between 2nd and 5th birthdays
4
Between 5th and 7th birthdays
5
Between 7th and 10th birthdays
6
Since 10th birthday but not in the past 12 months
7
In past 12 months
8
Don't know age
did this occur
1
At least once a week?
2
Usually less than once a week?
3
Less than once a month?
4
Frequency unknown?
Please describe what medication has been used in the past and/or currently.
Generic text
continue on back pages if necessary
Has the study teenager had bronchitis since his/her 10th birthday?
1
YES
2
NO
3
DON'T KNOW
Has the teenager had any of the following since 10 years?
1
German measles
2
Measles
3
Mumps
4
Whooping cough
5
Chicken pox
6
Meningitis
7
Glandular fever
8
None of above

Has the teenager had any operations since 10 years?

Tick all that apply at age ... years

1 - Tick

Age

1 - Tick

Age

1 - Tick

Age

1 - Tick

Age
Tonsillectomy or Ts and As
Hernia operation
Appendiscectomy
Operation for squint
Grommets
Gynaecological procedure (what? ...)
Has the teenager had any operations since 10 years? Gynaecological procedure (what? ...)
Generic text
Has the teenager had any operations since 10 years? No operation since 10 years
1
Tick
Has the study child been admitted to hospital since his/her 10th birthday?
1
YES
2
NO
3
DON'T KNOW
Please give total number of admissions since 10th birthday: No:
How many

Please list details of all hospital admissions since 10th birthday:

Age at admission (years) Number of nights in hospital Reason for admission and diagnosis Treatment including operations and other procedures Name and full address of hospital
Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many Generic textAgeGeneric textHow manyGeneric textGeneric textGeneric textHow manyGeneric textAgeGeneric textAgeHow manyGeneric textGeneric textGeneric textAgeGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow many
1st admission
2nd admission
3rd admission
Continue on back page if more than 3 admissions

Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday.

Col 1 In-Patient Col 2 Out-Patient

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

Operation
Accident
Asthma/Wheezy bronchitis
Upper respiratory tract infection(s) (including E.N.T. problems)
Chest infections
Urinary tract infections/investigation
Other infections
Convulsions
Heart investigation/treatment
Abdominal conditions not requiring operation
Disorders of bones and joints
Blood disorders including leukaemia/anaemia etc.
Tumours, neoplasms and other malignant conditions
Endocrine disorders (diabetes, thyroid, etc.)
Skin conditions
Eye conditions
Problems of nutrition (e.g. over or underweight etc.)
Emotional conditions (specify ...)
Any other conditions (What? ...)
Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday. Emotional conditions (specify ...)
Generic text
Please indicate any conditions for which the study teenager has been admitted to hospital overnight since 10th birthday. Any other conditions (What? ...)
Other

Hospital Outpatient Attendances

Since 10 yrs. has the study teenager attended (i) a hospital outpatient department, (ii) a casualty/accident department or (iii) a specialist clinic?
1
NO
2
YES, a hospital outpatient department
3
YES, a casualty department
4
YES, a specialist clinic
5
DON'T KNOW

Please give details of all conditions or illnesses resulting in attendance(s) since his/her 10th birthday:

Age at 1st attendance (years) Total number of attendances Diagnosis and treatment Name and address of department, hospital or clinic
AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text AgeHow manyGeneric textGeneric textHow manyGeneric textGeneric textAgeGeneric textHow manyGeneric textAgeGeneric textHow manyAgeGeneric text
1st illness
2nd illness
3rd illness
If more than 3 conditions use back page

Accidents

Has the study child had an accident requiring medical advice or treatment since his/her 10th birthday?
1
YES
2
NO
3
DON'T KNOW
Please give total number of accidents since 10th birthday. ... accidents
How many

Please list below details of all accidents since 10th birthday:

Age (years) Where did it happen? (road, home, school, etc.) What happened? Description of 'injuries' (e.g. burn/scald, fracture, head injury with unconsciousness etc) Treatment (including stitches, operation(s) plaster cast(s), traction etc) Where treated (GP, casualty, in-patient)?
AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge AgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAgeAgeGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textAge
1st accident
2nd accident
3rd accident
(more spaces available at back of this form)
Medical causes of school absence
How much time altogether has the study child missed from school in the past 12 months for reasons of ill-health or emotional disturbance?
1
None, or less than one week in all
2
Over one week and up to one month in all
3
Over one month and up to three weeks in all
4
Over three months in all
5
Missed school, but don't know for how long
6
Don't know whether missed school
7
Does not attend school Please state why:
Generic text

If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply).

-

1 - Tick

Colds, catarrh, sore throats, ear infections
Bronchitis or chest infections, including pneumonia or influenza
Asthma or wheeziness
Headaches
Bilious attacks or diarrhoea
Dysmenorrhoea
Abdominal pain
Convulsions, fits or turns
If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Emotional or nervous problems (What? ...)
1
Tick
Generic text
If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Infectious diseases (What? ...)
1
Tick
Generic text
If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Accident or injury (Please specify: ...)
1
Tick
Generic text
If absent for more than one week in all during the past 12 months, please indicate reason(s). (If not applicable, leave blank; otherwise tick all that apply). Other cause(s) (What? ...)
1
Tick
Other
Other 2
Has this teenager used any of the following services since 10 years of age? Child/family guidance service, child psychiatrist or educational psychologist
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Has this teenager used any of the following services since 10 years of age? General practioner service for: a check up
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Has this teenager used any of the following services since 10 years of age? General practioner service for: immunisation (what against ...)
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text
Has this teenager used any of the following services since 10 years of age? General practioner service for: injury/illness (what? ...)
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text
Has this teenager used any of the following services since 10 years of age? Dental hygienist
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Has this teenager used any of the following services since 10 years of age? Speech therapist (what for? ...)
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Generic text
Has this teenager used any of the following services since 10 years of age? Health visitor
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Has this teenager used any of the following services since 10 years of age? Other service(s) used (What? ...)
1
Yes in past 12 months
2
Yes between 10-15 years
3
Yes but not known when
4
Not known
Other

Has this teenager, your husband or yourself been to any of the following in the past 12 months?

(Why? ...) -

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text

1 - My Teenager

2 - My Husband

3 - Other Member of family

4 - Myself

Generic text
Acupuncturist
Homeopath
Faith healer
Osteopath/chiropractor
Hypnotist
Has this teenager, your husband or yourself been to any of the following in the past 12 months? Other "alternative medical helper" (Who? ...)
1
My Teenager
2
My Husband
3
Other Member of family
4
Myself
Other
Private Medical Care

During the last 12 months, which if any of the family has been treated on a private basis by a qualified medical doctor?

-

1 - No

2 - Don't know

3 - Yes & privately insured

4 - Yes but not privately insured

My teenager
My husband
Myself
What was the condition/illness? Study teenager
Generic text
What was the condition/illness? My husband
Generic text
What was the condition/illness? Myself
Generic text

Please enquire or state from your own knowledge if (a) the study teenager, and (b) any other member of the family, has had any contact with any of the following services since the study child's 10th birthday?

A Teenager B Other member(s) of the family

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

1 - Tick

Social Services or Social Work Department (including former Children's Department)
Educational Welfare Department
Careers Officer/Youth Employment Officer
Voluntary Social Work Agency (Please state which: ...)
Police
Probation Office
Please enquire or state from your own knowledge if (a) the study teenager, and (b) any other member of the family, has had any contact with any of the following services since the study child's 10th birthday? Voluntary Social Work Agency (Please state which: ...)
Generic text
please state why and who arranged the contact in the first instance:
Generic text
(more space available at back of this form)
Has the study teenager ever been taken to court (or children's hearing in Scotland) to your knowledge?
1
YES
2
NO
3
DON'T KNOW
please give as many details as you can:
Generic text

Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) TEENAGER

Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5

Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) MY HUSBAND

Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5

Please list all pills, medicines and other forms of medication brought/prescribed for/taken by your teenager, your husband and yourself in the past 4 weeks (Include maintenance or other medicines, contraceptives or medicaments prescribed by doctor or hospital, or bought directly from chemist, supermarket, etc. Also tranquillisers, sedatives, hypnotics, analgesics, medicinal products obtained direct from shops, etc.) MYSELF

Name/brand of substance Reason taken Where prescribed/obtained How often taken
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
3
4
5
Does your teenager have an impairment, a disability or a handicap? (By 'Impairment' we mean a physical or mental abnormality/illness. By 'Disability' we mean difficulty in doing one or more mental or physical activities that average 16 year olds can do. By 'Handicap' we mean a disability which interferes with the opportunities that others take for granted, e.g. problems with access/facilities in public buildings; not being considered for jobs he or she could manage if given a chance; other people are put off without even knowing what he or she is like.)
1
NO
2
YES, an impairment
3
YES, a disability
4
YES, a handicap
5
NOT KNOWN
Please describe his or her condition:
Long text

Section E: FAMILY FINANCES

Please explain that knowledge of the economic circumstances of families with teenage children is vital in this study of the development of teenagers in Britain.
What have been the source(s) of income of the household during the past 12 months?
1
Father's employment
2
Mother's employment
3
Brother's/sister's employment
4
Other adult member(s) of household's employment
5
Investments and/or private income
6
Annuities and pensions (other than Social Security)
7
Supplementary Benefit
8
Unemployment Benefit
9
Widow's Pension/Widowed mother's allowance
10
Sickness Benefit
11
One-parent Benefit
12
Housing Benefit
13
Mobility Allowance
14
Rent or Rates Rebate
15
Retirement Pension
16
Disability Pension
17
Attendance Allowance
18
Family Income Supplement
19
Any other source(s) (Please specify: ...)
Other

Combined Income of present parents

Please show the following table of incomes to the respondent and ask her to mark the income band which is appropriate. The figures refer to the COMBINED GROSS INCOME OF THE CHILD'S MOTHER AND FATHER. (Do not include Child Benefit, but include all other earned and unearned income before deductions for tax, national insurance, etc) Enter either as weekly or yearly sum WEEKLY INCOME
1
Less than £50
2
£50 - £99
3
£100 - £149
4
£150 - £199
5
£200 - £249
6
£250 - £299
7
£300 - £349
8
£350 £399
9
£400 - £449
10
£450 - £499
11
£500 and over
12
REFUSE TO ANSWER
13
UNCERTAIN
Please show the following table of incomes to the respondent and ask her to mark the income band which is appropriate. The figures refer to the COMBINED GROSS INCOME OF THE CHILD'S MOTHER AND FATHER. (Do not include Child Benefit, but include all other earned and unearned income before deductions for tax, national insurance, etc ) Enter either as weekly or yearly sum YEARLY INCOME
1
Less than £2600
2
£2600 - £5199
3
£5200 - £7799
4
£7800 - £10399
5
£10400 - £12999
6
£13000 - £15599
7
£15600 - £18199
8
£18200 - £20799
9
£20800 - £23399
10
£23400 - £25999
11
£26000 and over
12
REFUSE TO ANSWER
13
UNCERTAIN

Family Expenditure

How much money is spent each week/month by your household on the following goods, and how many people share the goods? (It is realised that this will be an estimate and very approximate.)

A Weekly Expenditure £ OR B Monthly Expenditure £ C Number of people sharing goods
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
Food and household sundries
Alcohol
Tobacco
Clothing
Travel
Entertainment
Have you, as a family, been seriously troubled by financial hardship in the past 12 months?
1
YES
2
NO
3
Uncertain
4
Don't know
5
Other reply (What? ...)
Other
Please can you give us any details?
Generic text

Section F: ACCOMMODATION

What accommodation do you occupy?
1
House or bungalow occupied by us
2
Flat or maisonette with our own front door
3
Flat or rooms in building shared with other households (i.e. not self-contained)
4
Mobile home, houseboat, caravan or tent
5
Other type of accommodation (What? ...)
Other
Is the house or bungalow.
1
Detached?
2
Semi-detached?
3
Terraced (including end of terrace)?
Please give the lowest floor on which living room(s) or bedroom(s) are situated:
1
Basement
2
Ground
3
Above ground (give floor ...)
Floor
When was your present accommodation built?
1
In past 10 years
2
Between 10 and 25 years ago
3
Between 25 and 40 years ago
4
1914-1945
5
Pre-1914
6
Don't know
Is your accommodation owned/rented by you? It is
1
Owned outright
2
Being bought on mortgage or loan
3
Rented from local authority/council
4
Privately rented (unfurnished)
5
Privately rented (furnished)
6
Tied to occupation of a household member
7
Other situation (What? ...)
Other
Could you/did you buy as a sitting tenant of the Council?
1
YES
2
NO
3
DON'T KNOW

How many rooms are there within your accommodation? (Do not count kitchen, bathroom or toilets, or any room used solely for business or trade purposes.)

-

0 - 0

1 - 1

2 - 2

3 - 3

4 - 4

5 - 5

6 - 6

7 - 7

8 - 8

9 - 9+

Number of bedrooms
Number of other rooms
Have you the use of the following? Bathroom
1
Sole Use
2
Shared Use
3
Lack this amenity
Have you the use of the following? Indoor lavatory
1
Sole Use
2
Shared Use
3
Lack this amenity
Have you the use of the following? Hot water supply
1
Sole Use
2
Shared Use
3
Lack this amenity
Have you the use of the following? Garden/yard
1
Sole Use
2
Shared Use
3
Lack this amenity
Please describe the kitchen. Which of the following applies?
1
Kitchen less than 6 feet wide and not used as a living room
2
Kitchen less than 6 feet wide and used as a living room
3
Kitchen 6 feet or more wide and not used as a living room
4
Kitchen 6 feet or more wide and used as a living room
5
No kitchen
6
Don't know
What methods of heating are regularly used at home in the winter and which of these do you use most often? Tick all that apply
1
Central heating: Oil
2
Central heating: Gas
3
Central heating: Electric (night storage)
4
Central heating: Other electric heating
5
Central heating: Solid fuel
6
Central heating: Communal supply
7
Other type of heating: Gas (bottled) paraffin
8
Other type of heating: Gas fires
9
Other type of heating: Oil-filled radiators
10
Other type of heating: Solid fuel
11
Other type of heating: Other heating (What ...)
12
No method of heating
Other
What methods of heating are regularly used at home in the winter and which of these do you use most often? Tick the one you use most often
Other
1
Central heating: Oil
2
Central heating: Gas
3
Central heating: Electric (night storage)
4
Central heating: Other electric heating
5
Central heating: Solid fuel
6
Central heating: Communal supply
7
Other type of heating: Gas (bottled) paraffin
8
Other type of heating: Gas fires
9
Other type of heating: Oil-filled radiators
10
Other type of heating: Solid fuel
11
Other type of heating: Other heating (What ...)
12
No method of heating
How much of your home is heated regularly in winter?
1
All
2
More than half
3
Half
4
Less than half
5
None
How many other people share the same bedroom as the study teenager? (If teenager has own bedroom, tick 0)
0
0
1
1
2
2
3
3+
How many people sleep in the same bed as the study teenager? (If teenager has own bed, tick 0)
0
0
1
1
2
2
3
3+

Does your teenager, your husband or yourself have a cough and do any of you spit up phlegm?

In early morning on waking: Cough In early morning on waking: Phlegm During day/night: Cough During day/night: Phlegm

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

1 - No

2 - Yes for up to 3 months each year

3 - Yes for 3 months or more each year

MY TEENAGER
MY HUSBAND
MYSELF

Section G: FAMILY HEALTH

Since the teenager's tenth birthday has anyone in the household had any severe or prolonged illness (medical, surgical or psychiatric) or any handicap or disability? Please include illness in mother, father, other adults and children in household; exclude study teenager).
1
YES, mother
2
YES, father
3
YES, other adult or child (exclude study teenager)
4
NO, no one in the household has been ill
5
DON'T KNOW

_person < 4