ADOLESCENT HEALTH SCREENING QUESTIONNAIRE (FAPS)

You can check the health risk level by yourself through a questionnaire programmed after long research. The questionnaire is completely anonymous. The answer you give will not be associated with your name, so please answer all questions as honestly as you can. The identity of the Adolescent child is kept secret by imparting an identity number to him/her and his/her date of birth noted. The software used to implement this tool generates, the level of health risk aquired by the adolescence.

  • You should answer all the questions to get optimum result.
  • You may stop participating at any time. Your decision not to participate, will not affect you negatively in any way

If you have any questions regarding the questionnaire or would like more information about the study, please contact Project Co-coordinator  - Prof. Sukanta Chatterjee at Adolescence Health Clinic, Head, Dept. of Pediatrics, Medical College Kolkata, 88, College Street, Kolkata; Phone : - 91.33.2219-8118, Email : sukantachatterjee@hotmail.com.
GENERAL
1. Are you male or female?
  Male Female No answer
2. What religion are you?
  Hindu Muslim Christian Sikh Others No answer
3. What is your mother tongue?
  Bengali Hindi English Others No answer
4. Who do you live with?
  Both parents Just Mother Just Father Mother & Step Father or Father & Step Mother Other Relatives (e.g. Grand parents, Uncle/Aunt etc.) Non relatives (e.g. In a youth institution, Hostel)
5. Are you married?
  Married Unmarried No answer
6. In the last year, did you work for pay when you were not in school?
  No answer No Yes, but rarely Yes, some of the time(e.g., vacations) Yes, most of the year
7. Do your parents (or people you live with) worry about not having enough money for essentials such as food, clothing or shelter?
  No answer No, never Yes, but only seldom Yes, nearly every month
MOTHER
 
8. My mother is a person who is easy to talk with
  Not at all Sometimes Almost always No answer
9. My mother is a person who believes in showing her love for me
  Not at all Sometimes Almost always No answer
10. My mother is a person who gives me a lot of care and attention
  Not at all Sometimes Almost always No answer
11. My mother is a person who is able to make me feel better when I am upset
  Not at all Sometimes Almost always No answer
12. My mother is a person who enjoys doing things with me
  Not at all Sometimes Almost always No answer
13. My mother is a person who often praises me
  Not at all Sometimes Almost always No answer
14. My mother is a person who makes me feel better after talking over my worries with her
  Not at all Sometimes Almost always No answer
15. My mother is a person who makes me feel like the most important person in her life
  Not at all Sometimes Almost always No answer
16. My mother is a person who cheers me up when I am sad
  Not at all Sometimes Almost always No answer
17. My mother is a person who smiles at me very often
  Not at all Sometimes Almost always No answer
18. How much your mother knows who your friends are?
  Doesn’t know Knows little Knows a lot No answer
19. How much your mother knows how you spend your money?
  Doesn’t know Knows little Knows a lot No answer
20. How much your mother knows what you do with your free time?
  Doesn’t know Knows little Knows a lot No answer
21. How much your mother knows where you are most afternoons after school?
  Doesn’t know Knows little Knows a lot No answer
FATHER
 
22. My father is a person who is easy to talk with
  Not at all Sometimes Almost always No answer
23. My father is a person who believes in showing his love for me
  Not at all Sometimes Almost always No answer
24. My father is a person who gives me a lot of care and attention
  Not at all Sometimes Almost always No answer
25. My father is a person who is able to make me feel better when I am upset
  Not at all Sometimes Almost always No answer
26. My father is a person who enjoys doing things with me
  Not at all Sometimes Almost always No answer
27. My father is a person who often praises me
  Not at all Sometimes Almost always No answer
28. My father is a person who makes me feel better after talking over my worries with him
  Not at all Sometimes Almost always No answer
29. My father is a person who makes me feel like the most important person in his life
  Not at all Sometimes Almost always No answer
30. My father is a person who cheers me up when I am sad
  Not at all Sometimes Almost always No answer
31. My father is a person who smiles at me very often
  Not at all Sometimes Almost always No answer
32. How much your father knows who your friends are?
  Doesn’t know Knows little Knows a lot No answer
33. How much your father knows how you spend your money?
  Doesn’t know Knows little Knows a lot No answer
34. How much your father knows what you do with your free time?
  Doesn’t know Knows little Knows a lot No answer
35. How much your father knows where you are most afternoons after school?
  Doesn’t know Knows little Knows a lot No answer
HOME
 
In your home how often does the following happen?
36. Your parents help you with your home work?
  Almost always Sometimes Never No answer
37. Your parents talk to you about how you are doing in school?
  Almost always Sometimes Never No answer
38. Family members enjoy your friend’s visit in your house?
  Almost always Sometimes Never No answer
39. Your parents listen to you & take your feelings seriously?
  Almost always Sometimes Never No answer
40. Family members pay more attention to your brother?
  Almost always Sometimes Never No answer
41. Your family has dinner together?
  Almost always Sometimes Never No answer
42. Members of the family joke & laugh together?
  Almost always Sometimes Never No answer
43. Family Members argue or fight?
  Almost always Sometimes Never No answer
44. Family members smoke cigarettes excessively?
  Almost always Sometimes Never No answer
45. Family members drink too much alcohol?
  Almost always Sometimes Never No answer
46. Family members even tried drugs/ things to get stimulated to have fun?
  Almost always Sometimes Never No answer
47. In the past school years, did one (or both) of your parents come to your school to participate in a meeting with students and teachers, or to see an after-school event?
  Almost always Sometimes Never No answer
FRIENDS
 
48. I have at least one friend that I am very close with
  Agree Somewhat agree Disagree No answer
49. I am a leader among my friends
  Agree Somewhat agree Disagree No answer
50. My friends are seriously concerned about my emotions
  Agree Somewhat agree Disagree No answer
51. I can talk to my friends if I have troubles at home
  Agree Somewhat agree Disagree No answer
52. My friends sometimes pressure me into doing things I do not want to do
  Agree Somewhat agree Disagree No answer
53. It is very important to me what my friends think of me
  Agree Somewhat agree Disagree No answer
DRINKS/SMOKE
 
Mark whether you think none, some, or most of your friends
54. Drink alcohol more than once a week (including beer, wine or liquor)
  None of my friends Some of my friends Most of my friends No answer
55. Smoke cigarettes every day
  None of my friends Some of my friends Most of my friends No answer
56. Have tried drugs at least once (including marijuana, sniffing glue, or injecting drugs)
  None of my friends Some of my friends Most of my friends No answer
57. Have ever stolen anything
  None of my friends Some of my friends Most of my friends No answer
58. Often get into fights with other young people
  None of my friends Some of my friends Most of my friends No answer
59. Are often in trouble with teachers at school
  None of my friends Some of my friends Most of my friends No answer
60. Have had serious boyfriend or girlfriend
  None of my friends Some of my friends Most of my friends No answer
Please mark how often your friends do the following in a month
61. Have had sexual exposure
  None of my friends Some of my friends Most of my friends No answer
62. Smoke cigarettes
  Never Have tried once Have tried a few times No answer
63. Drink alcohol (wine, beer, liquor)
  Never Have tried once Have tried a few times No answer
64. Smoke marijuana, sniff glue or other substances
  Never Have tried once Have tried a few times No answer
65. Use hard drugs like cocaine or heroine
  Never Have tried once Have tried a few times No answer
66. I don’t think it’s a problem if young people like me smokes cigarettes
  Agree Somewhat agree Disagree No answer
67. I don’t think it’s a problem if young people like me drink alcohol occasionally
  Agree Somewhat agree Disagree No answer
68. I don’t think it’s a problem if young people like me drink alcohol frequently (e.g. many times a week)
  Agree Somewhat agree Disagree No answer
69. I don’t think it’s a problem if young people like me try marijuana
  Agree Somewhat agree Disagree No answer
70. I don’t think it’s a problem if young people like me try drugs such as cocaine, heroine etc
  Agree Somewhat agree Disagree No answer
Please mark how often you do the following
71. Smoke cigarettes
  Never Have tried once Have tried a few times No answer
72. Drink alcohol (wine, beer, liquor)
  Never Have tried once Have tried a few times No answer
73. Smoke marijuana, sniff glue or other substances
  Never Have tried once Have tried a few times No answer
74. Use hard drugs like cocaine or heroine
  Never Have tried once Have tried a few times No answer
75. If you have tried any of the above how often you tried them (in the last month)?
  Never Have tried once Have tried a few times No answer
SCHOOL
 
Mark if you agree, somewhat agree or do not agree with the following statements
76. I enjoy my school
  Agree Somewhat agree Disagree No answer
77. I have many good friends in my school
  Agree Somewhat agree Disagree No answer
78. Teachers at this school care about the students
  Agree Somewhat agree Disagree No answer
79. There is at-least one teacher at school I can talk to if I have a problem
  Agree Somewhat agree Disagree No answer
80. I like participating in discussions in class
  Agree Somewhat agree Disagree No answer
81. I tried hard at school to do well
  Agree Somewhat agree Disagree No answer
82. I can ask my school friends for help with my studies if I need it
  Agree Somewhat agree Disagree No answer
83. It is important to me to get as much schooling as I can
  Agree Somewhat agree Disagree No answer
84. I never drop out from school
  Agree Somewhat agree Disagree No answer
85. I have some best achievements in school to remember
  Agree Somewhat agree Disagree No answer
86. My marks are better than last year
  Agree Somewhat agree Disagree No answer
87. I think that I have some learning problem
  Agree Somewhat agree Disagree No answer
88. Are you involved in extra curricular activities after school?
  No activities Irregular activities (Sports/Exercise/Other Regular activities (Sports/Exercise/Other) No answer
89. How often did you skip a class or entire school day this year without an excuse?
  Never Sometimes Often No answer
TOWN & NEIGHBORHOOD
 

Mark whether you agree, somewhat agree or do not agree with the following statements about your town

 
90. Families in my town help each other in need
  Agree Somewhat agree Disagree No answer
91. I feel safe in my town
  Agree Somewhat agree Disagree No answer
92. I like living in my town
  Agree Somewhat agree Disagree No answer
93. I am worried about violence or my safety in my town
  Agree Somewhat agree Disagree No answer
94. I am looking forward to moving out of my town as soon as I can
  Agree Somewhat agree Disagree No answer

If you have tried any of the above how often you tried them (in the last month)?
95. Smokes cigarette
  Once in a month Few times in a week Every day No answer
96. Drink alcohol (wine, beer, liquor)
  Once in a month Few times in a week Every day No answer
97. Smoke marijuana, sniff glue or other substances
  Once in a month Few times in a week Every day No answer
98. Use hard drugs like cocaine, heroine etc.
  Once in a month Few times in a week Every day No answer
What you already know about sexuality & reproductive health?
Mark or write in what you think is the right answer
99. Do you physically attracted to opposite sex?
  Never Sometimes Often No answer
100. Do you physically attracted to same sex?
  Never Sometimes Often No answer
101. Do you physically attracted to both sex?
  Never Sometimes Often No answer
102. Do you see nude picture, Pornography, Blue Film?
  Never Sometimes Often No answer
103. Do you ever had sexual exposure?
  Never Sometimes Often No answer
Please mark whether you think the following statements are true or false
104. To be effective, the pill has to be taken regularly, everyday
  True False No answer
105. Condoms protect against sexually transmitted infections
  True False No answer
106. Condoms protect against pregnancy
  True False No answer
107. The same STI can have different symptoms in men and women
  True False No answer
108. If one partner gets treated for an STI, it is not necessary for the other to be treated as well
  True False No answer
109. Having an STI increases the risk of getting HIV
  True False No answer
110. HIV can be transmitted through shaking hands or touching an infected person
  True False No answer
111. A person can look healthy and still have HIV
  True False No answer
112. Condoms protect against STI and HIV
  True False No answer
113. HIV can be transmitted through mosquito, flea or other insect bites
  True False No answer
114. HIV can be transmitted through sex without a condom
  True False No answer
115. HIV can be transmitted from mother to child during pregnancy
  True False No answer
116. HIV can be transmitted through used needles
  True False No answer
117. Please list three infections you think a person can get through sexual intercourse
a)
b)
c)
118. If you do know ways to prevent pregnancy please list 3 ways you know of?
a)
b)
c)
119. If you do know ways to prevent pregnancy please list 3 ways you know of?
  During the menstruation Right before her menstruation In the middle of the cycle Right after her menstruation No answer
MEDICAL HISTORY
120. Do you have any health problem?
  Yes No No answer
  Problem :
121. Did you have any health problems in past 12 months?
  Yes No No answer
  Problem :
122. Are you taking any medicine now?
  Yes No No answer
  Medicine :
123. Are you allergic to any medicine?
  Yes No No answer
  Medicine :

Please check whether you have questions or are worried about any of the following
124. Height
  Yes No No answer
125. Weight
  Yes No No answer
126. Mouth/teeth
  Yes No No answer
127. Blood pressure
  Yes No No answer
128. Neck/ Back
  Yes No No answer
129. Diet /Food/ Appetite
  Yes No No answer
130. Chest pain / Trouble breathing
  Yes No No answer
131. Coughing/ Wheezing
  Yes No No answer
132. Wetting the bed
  Yes No No answer
133. Skin (rash/acne)
  Yes No No answer
134. Skin colour
  Yes No No answer
135. Breasts
  Yes No No answer
136. Sexual organs/ Genitals
  Yes No No answer
137. Headaches/migraines
  Yes No No answer
138. Heart
  Yes No No answer
139. Ears/hearing/ear aches
  Yes No No answer
140. Menstruation/periods
  Yes No No answer
141. Dizziness/fainting
  Yes No No answer
142. Stomach ache
  Yes No No answer
143. Wet dreams
  Yes No No answer
144. Eyes/vision
  Yes No No answer
145. Nausea/vomiting
  Yes No No answer
146. Anger/temper
  Yes No No answer
147. Physical abuse
  Yes No No answer
148. Sexual abuse
  Yes No No answer
DIETARY BEHAVIOUR
 
149. How many times you take meals per day?
  One meal per day Two meals per day Moe than 2 meals per day No answer
150. Are you satisfied with your eating habbit?
  Never Sometimes Very Often No answer
151. Do you eat in secret?
  Never Sometimes Very Often No answer
152. How do you describe your weight?
  Very underweight Slightly underweight About the right weight Slightly overweight Very overweight
153. Which of the following are you trying to do about your weight?
  I am not trying to do anything about my weight Lose weight About the right weight Gain weight Stay the same weight
154. During the past 30 days, did you exercise to lose weight or to keep from gaining weight?
  Yes Sometimes No No answer
155. During the past 30 days, did you eat less food, fewer calories, or foods low in fat, vomit or take laxatives to lose weight or to keep from gaining weight?
  Yes Sometimes No No answer
156. During the past  30 days, did you exercise to gain weight?
  Yes Sometimes No No answer
157. During the past 30 days,did you eat more food, more calories, or foods high in fat to gain weight?
  Yes Sometimes No No answer
158. During the past 30 days, did you take any pills, powders or liquids without a doctor’s advice to gain weight/ lose weight?
  Yes Sometimes No No answer
159. During the past 30 days how many times per day did you usually drink milk or eat milk products?
  I did not drink milk or eat milk product during the past 30 days One time per day More than one time No answer
160. During the past 30 days how many times per day did you usually eat cereals (e.g. rice, chapatti etc.)?
  I did not eat cereals during the past 30 days One time per day More than one time No answer
161. During the past 30 days how many times per day did you usually eat proteins (e.g. egg, fish, meat, dal etc.?
  I did not eat proteins during the past 30 days One time per day More than one time No answer
162. During the past 30 days how many times per day did you usually eat fat (e.g. ghee, butter, oil etc.)?
  I did not eat proteins during the past 30 days One time per day More than one time No answer
163. During the past 30 days how many times per day did you usually drinks soft drinks?
  I did not drink soft drinks during the past 30 days One time per day More than one time No answer
164. During the past 7 days how many days did you eat a fast food?
  0 days 1 - 5 days More than 5 days No answer
VIOLENCE
165. During the past 12 months how many times you are seriously Injured?
  0 times 1 time More than 1 time No answer
166. During the past 30 days, on how many days did you carry a weapon, such as a gun, knife, club for protection or self defense?
  0 times 1 time More than 1 time No answer
167. During the past 12 months how many times did you belong to a gang activity?
  0 times 1 time More than 1 time No answer
168. During the past 12 months, how many times were you physically abused by an adult person?
  0 times 1 time More than 1 time No answer
MENTAL HEALTH

Think about your feelings and actions in the last 3 months. Then mark the correct response about you
169. I do not feel alone
  Not true Sometimes true Very often true No answer
170. I have plenty of friends
  Not true Sometimes true Very often true No answer
171. I look O.K
  Not true Sometimes true Very often true No answer
172. I am not sad
  Not true Sometimes true Very often true No answer
173. Things doesnot bother me all the times
  Not true Sometimes true Very often true No answer
174. Everything will work out for me
  Not true Sometimes true Very often true No answer
175. I do not destroy my things when I am angry
  Not true Sometimes true Very often true No answer
176. I do not destroy things belonging to others
  Not true Sometimes true Very often true No answer
177. I do not disobey at school
  Not true Sometimes true Very often true No answer
178. I do not cut classes or skip school
  Not true Sometimes true Very often true No answer
179. I do not lie or cheat
  Not true Sometimes true Very often true No answer
180. I do not steal things from places other than home
  Not true Sometimes true Very often true No answer
181. I do not use drugs for non-medical purpose
  Not true Sometimes true Very often true No answer
182. I like myself
  Not true Sometimes true Very often true No answer
Please mark the response which answer is best suitable for you
183. Have you any recreational activity like sports/music/picnic/outings in recent past?
  Never Sometimes Very often No answer
184. During the past 12 months how often have you been so worried about something that you could not eat or did not have appetite?
  Never Sometimes Very often No answer
185. Have you ever thought seriously about running away from home?
  Never Sometimes Very often No answer
186. During the past two weeks how often you felt sad or down or as though you have nothing to look forward to?
  Never Sometimes Very often No answer
187. During the past 12 months how often have you felt so worried about something that you wanted to use alcohol or drugs to feel better?
  Never Sometimes Very often No answer
188. Have you seriously thought about suicide?
  Never Sometimes Very often No answer
189. During the past 12 months did you actually attempt suicide?
  Never Sometimes Very often No answer
About Self
190. Explain your best qualities and weakness in a few words.
Best qualities
Weakness
191. If you could change one thing of your life or yourself, what it would be?
 
192. What are your fears?
 
193. What are are the problems for which you worry the most at present as a student?
 
194. What are are the problems for which you worry the most at present as a student?
a)
b)
c)
INFORMATION & ADVICE
 
195. I got information and advice from
  My mother My father My brothers, sisters, or cousins My other adult relatives My friends From a school lecture or presentation From my boyfriend/girlfriend From the radio or TV From newspaper, magazines, books From the internet
196. We would like to know where you get your information and advice on about alcohol, tobacco, drugs
  My mother My father My brothers, sisters, or cousins My other adult relatives My friends From a school lecture or presentation From my boyfriend/girlfriend From the radio or TV From newspaper, magazines, books From the internet
197. We would like to know where you get your information and advice on about sexuality, contraceptives, or pregnancy.
  My mother My father My brothers, sisters, or cousins My other adult relatives My friends From a school lecture or presentation From my boyfriend/girlfriend From the radio or TV From newspaper, magazines, books From the internet
198. We would like to know where you get your information and advice on about being sad or depressed
  My mother My father My brothers, sisters, or cousins My other adult relatives My friends From a school lecture or presentation From my boyfriend/girlfriend From the radio or TV From newspaper, magazines, books From the internet
199. Is there already a special place in your community where young people can go to obtain information or advice about alcohol, tobacco and drugs?
Please tell us what the place is
  No Yes No answer
200. Is there already a special place in your community where young people can go for advice when they are feeling sad or depressed?
If yes, tell place name
  No Yes No answer
201. Is there a health service in your community especially for young people like you?
If yes, tell place name
  No Yes No answer
HERE IS THE END OF THE QUESTIONNAIRE. YOU CAN NOW CALCULATE THE SCORE OR CLEAR THE ANSWER AND START AFRESH. AFTER YOU HAVE CALCULATED THE SCORE, PLEASE DO NOT FORGET TO SUBMIT THE SAME FOR OUR RECORD AND ANALISYS TO INTERACT WITH YOU IN THE FUTURE. pLEASE BE INFORMED THAT THE INFORMATION RECORDED WILL BE KEPY CONFIDENTIAL. THANK YOU.
      You received a score of
SCORE COMMENT
187 Low score - you have optimum health habits
188 to 374 Moderate score - meet a counselor
375 to 561 High score - need health check up
> 562 Very high score - need health check up

Contact Clinic/Counselor 91..33.22198118, mail: sukantachatterjee@hotmail.com
 
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