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Your Stay
Your Stay
Before You Visit
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Getting to Dewi Jones
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Change your appointment
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Ronald McDonald House
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A Healthier Future
A Healthier Future
Alder Hey in the Park
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The Speakman Building
Our Clinical Research Facility
Our Innovation Hub
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Springfield Park
The Department of International Child Health
Our Green Plan
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Congenital Heart Network
Groundbreaking Research
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Institute in the Park
NIHR Alder Hey Clinical Research Facility
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Paediatric Medicines Research Unit
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Join Us
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The Forum @ Alder Hey application form
Support Our Charity
Parent Questionnaire
For children under 7, parents/carers need to complete both the parent and the child version of this questionnaire.
Wellbeing in Diabetics Questionnaire - Parent/Carer Version
Name of child/young person with diabetes
*
Child/young person's DOB
*
Patient AH number (can be found at the top of your appointment letter)
*
Name of parent/carer
*
Relationship to child/young person
Mother
Father
Carer
Other
Date today (DD/MM/YYYY)
1. In the last month, has your child had any difficulties with the following areas:
a. Worrying about eating patterns or appetite
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
b. Feeling sad / low in mood
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
c. Worrying or feeling nervous
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
d. Home life or family relationships have been difficult
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
e. Struggling at pre-school, school, college or work
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
f. Having difficulty getting on with friends
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
g. Having difficulty doing what is needed to look after the diabetes e.g. testing, injections, pump, carb count etc.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
2. How well do YOU feel you are you managing your child's diabetes? (1 being "not very well at all" - 10 being "excellent"
1
2
3
4
5
6
7
8
9
10
3. In the last month, as a result of your child's diabetes, have you had any difficulties with:
a. Feeling tired
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
b. Feeling sad / low in mood
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
c. Worrying or feeling nervous
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
d. Home life or family relationships have been difficult
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
4. Is there anything else you are finding difficult or would like to discuss?
5. Would you like to:
a. Talk about the above with the diabetes team in clinic today?
Yes
No
b. Would you like the psychologist to make an appointment to see you on a separate occasion?
Yes
No
Next
The below should be completed on behalf of your child.
6. Is there anything you would like to ask or discuss in clinic today?
7. Please tick to show how much you agree with each statement. These statements are about you/the person with diabetes have been getting on in the last month:
a. Worrying about eating patterns or appetite
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
b. Feeling sad / low in mood
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
c. Worrying or feeling nervous
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
d. Home life or family relationships have been difficult
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
e. Struggling at pre-school, school, college or work
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
f. Having difficulty getting on with friends
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
g. Having difficulty doing what is needed to look after my diabetes e.g. testing, injections, pump, carb count etc.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
8. Is there anything else you are finding difficult or would like to discuss?
9. To complete in clinic:
Agreed plan:
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Alder Hey Children's Charity
Home
Your Stay
Your Stay
Before You Visit
Before You Visit
Getting to Alder Hey Children's Hospital
Getting to Dewi Jones
Getting to our community sites
What to bring
Change your appointment
When You Arrive
When You Arrive
Our atrium
Getting around
While You're Here
While You're Here
Your ward
Outpatients
Having surgery
Pharmacy
Spiritual care
Alder Hey arts
Facilities at Alder Hey
Local facilities
Ronald McDonald House
Share Your Feedback
Share Your Feedback
Messages of thanks
PALS - for queries and concerns
Complaints
Helpful Information for Young People
Other Information
Other Information
Patient information leaflets
Duty of candour
Overseas visitors
Subject access requests
Visitors and relatives charter
Alder Hey consent policy
Equality and diversity
Our Services
COVID-19 Information Hub
A Healthier Future
A Healthier Future
Alder Hey in the Park
Alder Hey in the Park
Our Hospital
The Speakman Building
Our Clinical Research Facility
Our Innovation Hub
Our Alder Centre
Springfield Park
The Department of International Child Health
Our Green Plan
Growing in Partnership
Growing in Partnership
Our Partners
Neonatal Care
Congenital Heart Network
Groundbreaking Research
Groundbreaking Research
Children & young people at the heart
Institute in the Park
NIHR Alder Hey Clinical Research Facility
Children's Nursing Research Unit
Paediatric Medicines Research Unit
Better, Safer Medicines
Infection
Rheumatic Disorders
Cancer Treatment
Research Clinics
Future Researchers
Pioneering Innovation
Education
Education
Alder Hey Academy
Paediatric Training
Strong Foundations
Strong Foundations
Outstanding Care
Best People
Our People
Our People
Patient referrals
Join Us
Join Us
Work at Alder Hey
Work at Alder Hey
Current vacancies
Nursing
Moving to Liverpool
Clinical work placements
Our recruitment process
Work experience
Volunteering
Volunteering
Volunteer Application
Become a Governor
Become a Member
Join Our Forum
Join Our Forum
The Forum @ Alder Hey application form
Support Our Charity