Family Background Questionnaire | Driscoll Health Plan

This questionnaire collects information about your family. Please read and answer every question. All information provided will be treated in strict confidence and will not be made available to any other source without your approval. All data gathered will be protected under the HIPPA privacy act.

* = required

Date

Select the Seminar you attended today:*

What is your participation number?*

What ZIP Code do you live in?*

Your Family

Child's Age*

Child's Gender*

Male
Female

Your relationship to this child*

You selected "Other", please let us know your relationship to this child:*

Your current marital status*

Currently, who lives at home with your child?*

(Select all that apply.)

Parent/Parents
Sibling/Siblings
Grandmother
Grandfather
Aunt
Uncle
Cousins

Which best describes the household in which your child is presently living?*

Original family (both biological or adoptive parents present)
Step-family (two parents, one being a step-parent)
Sole parent family
Other

You selected "Other", please describe the household:*

Your Education and Employment

Your highest level of education:*

Are you currently in paid employment?*

Yes
No

Do you have a partner or spouse living with you or helping you raise your children?*

Yes
No

Your partner’s highest level of education:*

Is your partner currently in paid employment?*

Yes
No

Your Health

In the last 6 months have you sought professional assistance from any of the following?*

If you said "Yes" to any of the items above, please provide details:

In the last 6 months has your partner sought professional assistance from any of the following?*

If you said "Yes" to any of the items above, please provide details:

Your Child’s Health

Does your child experience any of the following?*

	Yes	No
A vision or hearing impairment
A severe chronic illness that results in regular hospitalization
A physical disability
An intellectual disability
A developmental delay
A restrictive/therapeutic diet prescribed by a health professional

If you said "Yes" to any of the items above, please provide details:

Is your child having any regular contact with another professional or government agency for emotional or behavioral problems?*

Yes
No

Please provide details:*

	Yes	No
Psychologist
Psychiatrist
Counselor
Social Worker
Other Professional

	Yes	No
Psychologist
Psychiatrist
Counselor
Social Worker
Other Professional