What is your age? Under 18 Years Old 18 to 24 Years Old 25 to 30 Years Old 31 to 40 Years Old 41 to 50 Years Old 51 to 60 Years Old Over 60 Years Old What is your gender? Male Female How many hours a day do you see your child/children? less than 1 hour 1-3 hours 3-5 hours more than 5 hours Do you know your child's Doctor's name and phone number without looking it up? Yes, I know both No, I forget one No, I don't no either Do you go bars or out with your friends during the week? Yes No Do you curse at your child? Yes No Do you work? Yes, full-time Yes, part-time No, I am at stay at home parent Are you currently going to school? Yes No Would you ever choose anyone over your child? My spouse comes first, then my child No one comes before my child I choose my family before my child How many days a week do you go out without your child excluding work? 0-1 1-2 2-3 more than 3 Do you like being alone? Yes, I like alone time Yes, I always like to be alone No, I like to be aorund my child all the time Do you smoke infront of your child? Yes, right infront Yes, but not close to her/him/them No, I go into another room I do not smoke Do you drink infront of your child? I drink infront of her/him/them and sometimes get drunk I drink a little, but not much I do not drink infront of him/her/them I do not drink Do you have a babysitter or daycare? I have a babysitter that I know well I have a babysitter that someone reccommended to me I bring my chilld to daycare I do not require either service as of now Do you curse infront of your child? Yes, they don't understand I do not say bad bad words, just those little ones I do not curse at all infront of him/her/them I curse all the time, I can't help it Are you married? Yes I am No, but I am with the father/mother of my child/children No, I am with someone(not the parent of my child/children) I don't need a man/woman How is your relationship with your spouse? Great, couldn't love him/her more We have our problems Wish I were single I am single Do you currently know how much your child weighs? Yes, exactly Yes, somewhat No, have no idea Do you enjoy the drive home before you see your child/children? Yes, can't wait to see him/her/them uhhhh, gotta go home Please let me stay another hour at work/school I am moving Do you know your child's favorite TV show? He/She/They do not watch TV Yes No Are you on the computer right now while your child is running around? Yes, they are downstairs/upstairs/in the other room My child/children are right here No, he/she/they are sleeping Do you know how many teeth your child has? Yes, I know exactly I know approxiamately No idea Do you have a check up for your child scheduled? Yes No, I will do it later I am not sure Are you worried to see if "You are a good Parent"? No, I know I am Yes, I could use some work Yes, I have no clue what the results will be Are you on anything to do with the state?(i.e. WIC, Welfare, Medicade) No, I don't need that That is not for me, I would rather struggle Yes, and it does not bother me that I have it Yes, and I hate that I have to be on it
