Child Health & Well-Being Survey

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:

I have read and understood the above information.

I consent to provide my child's health-related information for this survey.

I authorize the foundation to use the information for the stated health assessment purpose.

I Agree to the Parent/Guardian Consent and Terms & Conditions

Cancel / Exit

Child & Family Profile

1. Child Name *

2. Mother's Name *

3. Age (Years) *

4. Gender * MaleFemaleOther

5. School/College Name *

6. Class/Grade *

7. Height *

cm

8. Weight *

kg

9. Residential Area

10. Contact Number *

11. Family Type Joint FamilyNuclear Family

12. Number of Family Members

Health History

13. Birth Weight (kg, if known)

14. Type of Delivery Normal DeliveryCaesarean Delivery

15. Was the child breastfed? YesNo

16. Duration of Breastfeeding (months)

17. Any major illness during infancy? YesNo

18. History of frequent hospital admissions? * YesNo

Child Health Status *

Health Condition	Yes	No
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 *

19. Number of sick days in last 12 months *

20. Any diagnosed medical condition? * YesNo

Family Health History

Condition	Yes	No
Obesity
Diabetes
High Blood Pressure
Heart Disease
Thyroid Disorders
Asthma/Allergies
Autoimmune Disorders

Nutrition & Healthy Eating

Lifestyle & Daily Habits

Hygiene Practices

Emotional Well-being & Learning

Emotional Well-Being

Question	Yes	No
Generally happy
Frequently anxious
Easily irritated
Difficulty concentrating
School stress
Difficulty social interaction
Experiences bullying
Participates in hobbies

65. School Attendance *

%

66. Academic Performance * ImprovingStableDeclining

67-69. Concerns

Attention: YesNo Hyperactivity: YesNo Memory: YesNo

70. Teacher Concerns

Child Health & Well-Being Survey