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* 1. How many children do you have?

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* 2. What are the ages of your children?

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* 3. What best describes your household?

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* 4. Where are you living now?

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* 5. Have any of your children (age 5-21)...

  yes no
been to a doctor or nurse in the past year?
seen a dentist in the past year?
seen a counselor in the past year?
had an eye exam in the past year?

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* 6. Were there any times in the past year when you wanted to take your child (age 5-21) to a doctor or nurse but couldn't?

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* 7. Are there barriers that make it difficult for you to take your child/children (age 5-21) to the doctor or nurse? (check all that apply)

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* 8. Where do you usually take your child/children (age 5-21) for health care? (check all that apply)

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* 9. Have any of your children (age 5-21) had any of the following health care needs within the past year?

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* 10. What type of health insurance do you have for your child/children (age 5-21)? (check all that apply)

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* 11. In your opinion, what are some child and adolescent health problems that concern you? (check all that apply)

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* 12. What services and education programs would you like a School Based Health Center to provide?

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* 13. Other comments?

T