Parent/Guardian Consent & Terms of Participation

Child Health & Well-Being Survey

Before proceeding, please read and confirm your consent.

1. Purpose of the Survey

This survey is conducted to understand the health, nutrition, lifestyle, physical activity, and overall well-being of children aged 5-21 years. The information collected will help in health assessment, awareness, and planning of preventive health initiatives.

2. Parent/Guardian Participation

I confirm that I am the child's mother/parent/legal guardian/primary caregiver and I am providing information based on my knowledge of the child's health, habits, and history.

3. Accuracy of Information

I understand that the quality of the assessment depends on the accuracy of the information provided. I will provide truthful and complete information to the best of my knowledge.

4. Health Information Collection

I understand that the survey may collect information related to: Child profile details, Birth and early childhood history, Health conditions, Food and nutrition habits, Physical activity, Sleep patterns, Screen time, Emotional well-being, Family health history, Hygiene practices.

5. Use of Information

The information provided may be used for: Child health assessment, Identifying health and lifestyle risks, Providing general health guidance, Creating awareness programs, Improving child wellness initiatives.

6. Privacy & Confidentiality

The collected information will be kept confidential and will be accessed only by authorized personnel involved in the health assessment program. The information will not be publicly displayed or shared for commercial purposes without additional permission.

7. Voluntary Participation

Participation in this survey is voluntary. I understand that I may choose not to complete the survey or withdraw my participation where applicable.

8. Medical Disclaimer

This survey is intended for health assessment and awareness purposes only. It does not replace professional medical advice, diagnosis, or treatment by a qualified healthcare professional.

9. Consent Confirmation

By selecting "I Agree", I confirm that:


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Child Health & Well-Being Survey

Age Group: 5-21 Years — Foundation Health Assessment Program

Section A: Child Profile
Section B: Birth & Early Childhood History
Section C: Current Health Status
Health ConditionYesNo
Frequently falls sick
Frequent fever
Frequent cold/cough
Allergies
Asthma/Breathing problems
Skin problems
Digestive problems
Constipation
Acidity/Stomach pain
Frequent headaches
Body/joint pain
Dental problems
Vision problems
Hearing problems
Section D: Nutrition & Food Habits
Section E: Traditional Indian Food Practices
Section F: Physical Activity
Section G: Screen Time
Section H: Sleep Health
Section I: Mental & Emotional Well-Being
QuestionYesNo
Generally happy
Frequently anxious
Easily irritated
Difficulty concentrating
School stress
Difficulty social interaction
Experiences bullying
Participates in hobbies
Section J: Academic & Behavioural Indicators
Attention:
Hyperactivity:
Memory:
Section K: Family Health History
ConditionYesNo
Obesity
Diabetes
High Blood Pressure
Heart Disease
Thyroid Disorders
Asthma/Allergies
Autoimmune Disorders
Section L: Hygiene Practices
Section M: Observation by Survey Team
ObservationYesNo
Signs of Undernutrition
Signs of Obesity
Signs of Anemia
Dental Caries
Vision Concerns
Posture Issues
Skin Health Issues
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