Please answer all of the following questions carefully for the health inspection. Any information you provide is confidential.
	
1. Pupil’s name and school	Last name and first name
     	Personal identity number
     	
	School and class
     	Pupil’s phone number
     	
2. School attendance and friendships	How are you doing at school?
     	
	What things do you like about school?
     	
	What things do you not like about school?
     	
	Which subjects are you good at?
     	
	Do you have help with homework?
     	
	Do you find that your teachers or other adults at school provide you support and encouragement?
     	
	Do you have friends at school and outside school?
     	
	Are you being bullied?
     	Do you bully others?
     	
3. Health routines	What are your eating habits like?
     	
	At what time do you go to bed at weekdays?
     	At what time do you go to bed at weekends?
     	
	Is anything bothering your sleep? Please specify.
     	
	Do you smoke or use snuff?
     	How much do you smoke or use snuff? 
     	
	Do you use alcohol?
     	How often do you use alcohol / How much do you use alcohol at a time?      	
	What do you think about drugs?
     	
	How do you spend your free time (sports, exercise, hobbies)?
     	
	How much time do you spend in front of a screen per day? (Computer, television, video game consoles, etc.)
     	
4. Health	Do you feel healthy?
     	
	Do you often experience headache, stomach pain, nervousness, fears or other uncomfort/symptoms?
     	
	Are you worried about something related to your health?
     	
	Do you have any diagnosed diseases? (Allergy, asthma, etc.) Please specify.
     	
	Do you need to take any medication occasionally or regularly? What medication?
     	
	How do you take care of your teeth?
     	
	What can you do to impact your health?
     	
5. Puberty and development	Are you happy with your growth and development?
     	
	Girls should answer the following questions	Boys should answer the following questions	
	Have your periods started?
     	At what age?
     	Have you started to ejaculate?
     	At what age?
     	
	Is menstrual pain affecting your school attendance? 
     	Is your foreskin too tight?
     	
	Currently, do you date? Do you need to use protection?
     	
	Do you have any questions related to sexuality or sexual identity?
     	
	Has anyone done anything to you against your will (sexual innuendo, touching, pressuring, abuse or violence)?
     	
6. Current situation	Are you happy with yourself?
     	
	Are you worried about anything related to yourself, your friends, your home or school?
     	
	Has your family gone through any changes which affect your schoolwork and well-being? Please specify. (Moving, parents’ divorce, illness in family, etc.)
     	
	Are you able to talk with your parents or another adult about matters that are important to you? 
     	
	Do you have a friend you can count on?
     	
	In your opinion, what are your strengths?
     	
	What are your future aspirations, dreams, plans?
     	
7. Signature	Date and Signature
     	

Thank you for your answers!