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. Author manuscript; available in PMC: 2017 Jun 29.
Published in final edited form as: Pediatr Emerg Care. 2011 Nov;27(11):1009–1013. doi: 10.1097/PEC.0b013e318235bb4f
Parental chronic medical or health problem (yes/no)
Parental chronic mental health problems (yes/no)
Difficulties involving the pregnancy of the child (yes/no)
Difficulties involving the delivery of the child (yes/no)
Prematurity of the child (yes/no)
Child kept in a special or intensive care nursery at birth (yes/no)
Child has chronic medical problems (parent-reported) (yes/no)
Child takes any medications long-term/chronically (yes/no)
Child takes any medications short-term/occasionally (yes/no)
Child has experienced any life-threatening illnesses (parent-reported) (yes/no)
Child sleeps with his/her parents (yes/no)
Child has sleep difficulties (parent-reported) (yes/no)
Child has behavioral or mental health difficulties (yes/no)
Child has developmental difficulties (yes/no)
Number of parent-reported visits to the private doctor’s office in the past year
 □ 0 □1–2 □ 2–3 □ 3–4 □ 4–5 □ 5–6 □ 6–7 □ 7–8 □ 8+
Number of parent-reported calls to the doctor’s office in the past year
 □ 0 □1–2 □ 2–3 □ 3–4 □ 4–5 □ 5–6 □ 6–7 □ 7–8 □ 8+
Number of parent-reported visits to emergency rooms/urgent care in the past year
 □ 0 □1–2 □ 2–3 □ 3–4 □ 4–5 □ 5–6 □ 6–7 □ 7–8 □ 8+
Number admissions to the hospital overnight (parent-reported)
 □ 0 □1–2 □ 2–3 □ 3–4 □ 4–5 □ 5+
Number of admissions to the intensive care unit (parent-reported)
 □ 0 □ 1–2 □ 2+
Number of school days missed in the last year
 □ 0 □ 1–5 □ 5–10 □ 10–15 □ 15–20 □ 20+
Parental satisfaction with primary doctor’s office or clinic (1- to 10-point scale)
Parental satisfaction with ED or urgent care visits (1- to 10-point scale)