By unknown,

” This survey is to help LA Youth find out about you and your health habits. If you answer every question, you will be entered in a drawing for $50 and a free copy of the new LA Youth anthology! Two winners will be chosen. The deadline is February 16, 1999. The winner of our last survey was Dawnette Dungee of Verdugo Hills High School.
Teachers: You are also eligible for a prize. When you send in a set of surveys from your students, include a piece of paper with your name, school and address. We will select one teacher to receive $50 and a copy of the LA Youth anthology.
Here’s how to enter your survey. Fill out this questionnaire and mail it in to LA Youth. Please feel free to make as many copies as you like and give them to as many other students as you want. One survey—only one—per student, please. Mail the questionnaire to:
Health Survey
LA Youth
6030 Wilshire Blvd. Ste. 201
Los Angeles CA 90036

1. My age: (write in) ______

2. My grade: (write in) ______

3. My school: (write in) __________________

4. My race or ethnicity:
(Check all the answers that describe you best)
q A. White
q B. Black
q C. Latino/ Hispanic/ Mexican
q D. Asian
q E. Native American
q F. Other (write in) _____________________

5. My sex: A. Male B. Female

6. The problem with school is…
(Check all that apply)
q A. The other kids bug me
q B. The teachers are too busy to help me
q C. Too much homework
q D. I don’t feel safe on the way to or from school
q E. I don’t feel safe while I’m at school
q F. It’s boring or annoying
q G. Overcrowded classrooms
q H. It emphasizes grades over education
q I. I don’t have a problem with school
q J. Other (write in) __________________

My activities and goals:

7. Check all the activities you have
participated in during the last week:
q A. I played an organized sport (football, soccer, basketball, etc.)
q B. I went for a walk or hike
q C. I played a recreational sport (surfing, skating, etc.)
q D. I hung out with my friends
q E. I took a class outside of school in music, art or drama
q F. I went to a support group
q G. I went to church (or other place of religion)
q H. I ate dinner with my family
q I. I went to see a therapist or counselor

Tell us how important the following topics are to you:
(Check one response)

8. Getting a job now
q Extremely important q Somewhat important
q Not too important q Not at all important

9. Doing well in school
q Extremely important q Somewhat important
q Not too important q Not at all important

10. Getting into college
q Extremely important q Somewhat important
q Not too important q Not at all important

11. Having a successful, well-paying job in the future
q Extremely important q Somewhat important
q Not too important q Not at all important

12. I know where to go if…
(Check all that you know of)
q A. I want free or reduced cost health care
q B. I want info on birth control or pregnancy
q C. I want info on sexually transmitted diseases
q D. I want to play sports after school
q E. I want to have fun
q F. I want to go somewhere on the bus
q G. I want to use the library
q H. I want to hang out with other teens in a safe place
q I. I want to take an art, music or drama class
q J. I want to talk to someone about a problem I’m having

13. Of the following services, which ones are easy to get to, right in your neighborhood or at school? (Check all that are easy to get to)
q A. Using the library
q B. STD and/or pregnancy info
q C. Playing sports after school
q D. Going somewhere on the bus
q E. Hanging out with other teens in a safe place
q F. Free or reduced cost health care
q G. Talking to someone about a problem I’m having
q H. Taking an art, music or drama class
q I. Having fun

Tell us how important it is to do the following:
(Check one response)
14. Get along with my friends
q Extremely important q Somewhat important
q Not too important q Not at all important

15. Get along with my parents or family
q Extremely important q Somewhat important
q Not too important q Not at all important

16. Keep my virginity
q Extremely important q Somewhat important
q Not too important q Not at all important

17. Avoid getting pregnant or getting someone pregnant
q Extremely important q Somewhat important
q Not too important q Not at all important

18. Check all the things you did in the last week:
q A. I ate too much junk food
q B. I didn’t get enough sleep
q C. I went to a movie
q D. I smoked cigarettes
q E. I used an illegal drug (such as marijuana)
q F. I drank alcohol
Check all the things you did in the last week:
q G. I rode a bicycle
q H. I talked to someone about my sexual orientation
q I. I participated in a youth group
q J. I worked out at a gym or somewhere else
q K. I went to a dance club

Health
19. I brush my teeth…
q A. Twice a day or more
q B. Once a day
q C. Several times a week
q D. Once a week or less

20. I go to the dentist…
q A. Twice a year or more
q B. Once a year
q C. Not sure
q D. I’ve never been to the dentist

21. How I feel about going to the dentist…
q A. I hate it
q B. It’s not too bad
q C. I enjoy it
q D. I don’t know

Regarding my teeth… (Check all that apply)
q 22. I have braces.
q 23. I have fillings.
q 24. I had a toothache last week.

Regarding my doctor… (Check all that apply)
q 25. I go to the doctor once a year or more.
q 26. I have a regular doctor.
q 27. I have missed school to care for a sick family member.
q 28. I have had to translate instructions on how to take medication for someone I know.

Regarding myself… (Check all that apply)
q 29. I am a virgin.
q 30. I am disabled.
q 31. I learned English as a second language.
q 32. (For girls only) I have had a gynecological exam.
q 33. (For girls only) I have had a Pap smear.

34. In the past year, I have been to the doctor because I was sick or hurt…
q A. Never
q B. Once
q C. Twice
q D. More than twice

35. In the past year, I have been to the emergency room because I was sick or hurt…
q A. Never
q B. Once
q C. More than once

36. I go to the doctor…
q A. By myself
q B. With a parent
q C. With someone else

37. My family has health insurance.
q A. Yes
q B. No
q C. Don’t know

Wait, you’re not done yet!
Turn the page

38. When I or someone in my family needs medical attention, the biggest problems are…
(Check all those that apply)
q A. We don’t like doctors
q B. We don’t have insurance
q C. We can’t afford it
q D. We don’t know where to go
q E. We don’t have transportation to get there
q F. All the places are closed by the time a parent gets home from work
q G. Doctors don’t speak my parent’s language
q H. It takes too long/ we always have a long wait
q I. At the hospital, we might catch another disease
q J. Going to the doctor is confusing or scary

39. I have had my eyes checked…
q A. Last year
q B. When I was a kid
q C. In the last few years
q D. Never

40. Regarding my eyesight…
q A. I wear glasses and/or contact lenses
q B. I don’t wear either
q C. I don’t wear them, but I think I might need them

41. I have had the following health problems
(List any that you are concerned about)

________________________________________

42. Please check off all of the following that may describe you:
q A. I have been depressed
q B. I have considered suicide
q C. I have attempted suicide

43. When I was depressed, I talked to…
(Check all that apply)
q A. A teacher
q B. A friend
q C. A counselor/therapist
q D. A parent
q E. Another relative
q F. No one
q G. Support group
q H. I haven’t been depressed
q I. Other: (write in) ________________

44. When I was worried about my friend’s health, I talked to… (Check all that apply)
q A. Another relative
q B. A counselor or medical professional
q C. A friend
q D. A parent
q E. A teacher
q F. No one
q G. Other: (write in) ________________

45. When I was worried about my own health, I talked to… (Check all that apply)
q A. A counselor or medical professional
q B. A friend
q C. A teacher
q D. A parent or relative
q E. No one
q F. Other: (write in) ________________

46. I wish I could… (Check all that apply)
q A. Get health insurance
q B. Get buff
q C. Gain weight
q D. Lose weight
q E. Get taller
q F. Get rid of my pimples
q G. Be healthier
q H. Have better teeth

School
47. Last week I was absent for…
q A. I wasn’t absent
q B. One day of school
q C. Two days of school
q D. Three days of school
q E. Four days of school
q F. Five days of school
q G. There was no school
q H. I don’t go to school

48. How I feel about the school nurse…
(Check all that apply)
q A. Teens can go there to discuss a problem
q B. Teens can get birth control and info
q C. I don’t know where the nurse’s office is
q D. The nurse doesn’t like students
q E. The nurse can’t really help you if you need medical attention
q F. Teens only go there to get out of class
q G. I have never been to the nurse’s office

49. What I like about school is… (Check all that apply)
q A. It’s safe there
q B. I’m learning something
q C. I have friends
q D. The teachers help me
q E. Other (write in) ______________________

Family Life
50. How many people live in your household including yourself (write in) ________

51. I live with…
(check the one for where you are living now)
q A. Parents
q B. Parents and siblings
q C. Mother only
q D. Mother and siblings
q E. Father only
q F. Father and siblings
q G. Foster family
q H. Group home
q I. Someone else (write in) ____________

52. When I get home from school today (or on the next school day)… (check one)
q A. No adults will be around for at least an hour
q B. No adults will be around for at least two hours
q C. No adults will be around for at least three hours
q D. No adults will be around for at least four hours
q E. There will be at least one adult around
q F. I don’t know

53. At home I speak the following languages…
q English q Spanish
q Other (write in) __________________

54. I was born in… (write in country of birth)

____________________________

55. I have lived in the United States:
q A. All my life
q B. I moved here in (write in year)
19 _______

56. My family and I have lived at our current address… (Check one)
q A. Less than one year
q B. About one year
q C. Two to four years
q D. More than five years

57. In the last week, I… (Check all that apply)
q A. Helped or tutored another student
q B. Completed my homework
q C. Helped the teacher
q D. Did extra credit work
q E. Helped around the school
q F. Got a good grade on a test
q G. Studied with a friend
q H. Did community service

58. In the last year, I successfully changed a habit.
(Check all that apply)
q A. I stopped smoking
q B. I stopped swearing
q C. I studied more
q D. I stopped gossiping about others
q E. I got more sleep
q F. I got more exercise
q G. I ate more healthily
q H. I stopped watching TV as much
q I. I stopped drinking or using drugs
q J. I fought less with parents or siblings
q K. I stopped ditching
q L. I read more
q M. I felt more positive about life
q N. I stopped hanging out with people who were a bad influence.
q O. Other (write in) __________________

59. If you could, what would you change? (Check all that apply)
q A. the way I look
q B. my school performance
q C. the people I associate with
q D. I want to stop smoking
q E. I want to stop partying so much
q F. I want a boyfriend or girlfriend
q G. I want a better relationship with my parents or family
q H. I want a better relationship with God
q I. I want to improve my self-esteem

60. What’s stopping you from making these changes? (Check all that apply)
q A. I don’t have any help (such as supportive adults, information, classes)
q B. I don’t really want to change
q C. I don’t know how
q D. I tried but it’s too hard
q E. My friends put pressure on me to do certain things
q F. It takes too much time
q G. It’s too embarrassing

The following information is optional, however you must fill out the survey in full to be eligible for the free LA Youth anthology and $50. Your personal information will be kept confidential.

61. My name (write in) _______________________

62. My home address is: (write in)

Street address __________________________________

City ________________________

63. Zip code _________________

64. My home phone (______) _______________

Mail the questionnaire to:
Health Survey
LA Youth
6030 Wilshire Blvd. Ste. 201
Los Angeles CA 90036″