Teens Healthy Bones & Joint Program

To assist AOWA in evaluating the effectiveness of this program, the below is a data gathering tool to collect valuable information before your child commences the program and is repeated at 1 week prior to the end of term (Week 7). As the parent/guardian of your child registered in this program, we would appreciate your valued contribution through the completion of this form.

Below are a list of things that might be a problem for you. Please tell us how much of a problem each one has been for you during the PAST MONTH by selecting the most suitable answer from the drop-down menu:

0 if it is never a problem
1 if it is almost never a problem
2 if it is sometimes a problem
3 if it is always a problem
4 if it is almost always a problem There are no right or wrong answers.
If you do not understand a question, please ask for help.

When you have completed the form and answered all questions, please click the SUBMIT button.

Peds QL Form

Child's Name:(Required)

First Name Surname

Age:(Required)

About My Health and Activities (problems with ....)

1. It is hard for me to walk more than a couple of streets (about 100 metres)(Required)

2. It is hard for me to run(Required)

3. It is hard for me to do sports activities or exercise(Required)

4. It is hard for me to lift heavy things(Required)

5. It is hard for me to have a bath or shower by myself(Required)

6. It is hard for me to do chores around the house(Required)

7. I have aches and pain(Required)

8. I feel tired(Required)

About My Feelings (problems with....)

1. I feel afraid or scared(Required)

2. I feel sad(Required)

3. I feel angry(Required)

4. I have trouble sleeping(Required)

5. I worry about what will happen to me(Required)

How I Get On with Others (problems with....)

1. I have trouble getting on with other teenagers(Required)

2. Other teenagers do not want to be my friend(Required)

3. Other teenagers tease me(Required)

4. I cannot do things that other teenagers my age can do(Required)

5. It is hard to keep up with other teenagers my age(Required)

About School (problems with....)

1. It is hard to pay attention in class(Required)

2. I forget things(Required)

3. I have trouble keeping up with my school work(Required)

4. I miss school because of not feeling well(Required)

5. I miss school to go to the doctor or hospital(Required)

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Teens Healthy Bones & Joint Program

Peds QL Form

About My Health and Activities (problems with ....)

About My Feelings (problems with....)

How I Get On with Others (problems with....)

About School (problems with....)

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