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Alto Elementary Wellness Check-in
Please complete this form for each of your children in grades K-5.
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* Indicates required question
Student Name:
*
Your answer
Student's grade:
*
Kindergarten
First
Second
Third
Fourth
Fifth
Your relationship to the student:
Your answer
For the next few questions, think about whether you have seen a change in your child's behavior over the last three months (since the beginning of August).
Ability to concentrate or pay attention
*
No change
1
2
3
4
5
Significant change
Sleep patterns (going to sleep, staying asleep, bedtime routine)
*
No change
1
2
3
4
5
Significant change
Relationships with friends
*
No change
1
2
3
4
5
Significant change
Relationships with family
*
No change
1
2
3
4
5
Significant change
Handling transitions
*
No change
1
2
3
4
5
Significant change
Increased focus in a specific area
*
No change
1
2
3
4
5
Significant change
Physical health (for example: frequent stomachaches, headaches, eating habits, etc.)
*
No change
1
2
3
4
5
Significant change
Emotional responses
*
No change
1
2
3
4
5
Significant change
Other area in which you have seen a change:
Your answer
Has your family been impacted in any of the following ways as a result of the pandemic? (Check any that apply)
Financial
Heath
Living Situation
Social Interactions
Someone close to the family was significantly ill and/or passed away
Other:
How has your child handled the transition to school this year?
Your answer
Thank you for your time.
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