Responded

HOME
YES NO
Any problems in the family that
1 directly concerns you
Parents/Guardian listens and take
2 feelings seriously
Have ever been seriously thought of
3 running away from home
Have any major family changes in
4 the past years
EDUCATION

1 Studying

2 Working

3 Having Problems in school/work

experienced bullying in school or at
4 any other occasion

EATING HABBITS
Satisfied with the way they look and
1 weight
2

Tried to lose weight or maintain by

vomiting, taking diet, lacatives or
starting the self.
Somebody pointd out that you have
3 gained weight ot lose weight

ACTIVITIES
Participates in any sports or
activities in School, at work, at
1 home.

2 Exercise regularly.

3 Using internet/computer.

DRUGS
Have ever used (Tobacco, Alcohol,
1 Stree drugs, Prohibited drugs)

SEXUALITY
concerns regarding health and body
1 changes

2 Ever had sex

3 Partners have had in previous years

thinking of being a gay, lesbian or
4 bisexual
Ever been pregnant or gotten
5 someone pregnant

6 Had sexually transmitted infection

had used any form of protection
7 when have sex
SAFETY/WEAPONS/VIOLENCE

Ever been
1 touched/hit/slapped/kicked/pushed
or shoved in any way by any person
2 Currently in a relationship were
physically hurt, threatened or made
feel afraid

3 Wear a seatbelt when riding a car

lived with having a gun, rifle or
4 firearm

SUICIDE/DEPRESSION

1 Feeling anxious, sad and depressed

Thought of hurting or ending life in

2 any way
3

Members of the family with history

of suicide, depression or anxiety
MARILYN A BAYHI