{"id":2742,"date":"2023-05-03T12:15:47","date_gmt":"2023-05-03T09:15:47","guid":{"rendered":"https:\/\/www.anasa.com.gr\/erotimatologio-anilikon\/"},"modified":"2023-08-02T13:47:45","modified_gmt":"2023-08-02T10:47:45","slug":"adolescent-questionnaire","status":"publish","type":"page","link":"https:\/\/www.anasa.com.gr\/en\/adolescent-questionnaire\/","title":{"rendered":"Adolescent Questionnaire"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2750-o1\" lang=\"el\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/2742#wpcf7-f2750-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2750\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"el\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2750-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"uacf7-form-2750\"><div class=\"erothmatologio-efhvon vc-border\">\n\n<div class=\"vc-row \">\n\t\t\t\t<div class=\"vc-col-12 vc-text-center mb-40\"><h4>ADULT QUESTIONNAIRE<\/h4><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12 vc-text-right\"><label> DATE: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-form\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-05-01\" max=\"2026-05-01\" step=\"3\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-05-01\" type=\"date\" name=\"date-form\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20\">\n\t\t\t\t<div class=\"vc-col-6\"><label> FATHER OR MOTHER CONTACT PHONE: <span class=\"wpcf7-form-control-wrap\" data-name=\"tel-epikoinonias\"><input size=\"40\" maxlength=\"10\" minlength=\"10\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-epikoinonias\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label> EMAIL: <span class=\"wpcf7-form-control-wrap\" data-name=\"email-epikoinonias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-epikoinonias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-4\"><label>CHILD\u2019S NAME: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-onoma-paidiou\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-onoma-paidiou\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label>FATHERS NAME: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-onoma-patera\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-onoma-patera\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label>MOTHERS NAME: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-onoma-miteras\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-onoma-miteras\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-40 mt-20\">\n\t\t\t\t<div class=\"vc-col-12\"><p class=\"vc-text-center\">Please then answer the following questions<\/p><\/div>\n\t\t<\/div>\n\t\t\n\t\t\t\t<div class=\"vc-row vc-border-b\">\n\t\t\t\t<div class=\"vc-col-3\"><label> AGE<span class=\"wpcf7-form-control-wrap\" data-name=\"text-ilikia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-ilikia\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ilikia\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-3\"><label> CLASS<span class=\"wpcf7-form-control-wrap\" data-name=\"text-taksi\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-taksi\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-taksi\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-3\"><label> SEX<span class=\"wpcf7-form-control-wrap\" data-name=\"text-fulo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-fulo\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-fulo\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-3\"><label> DOES YOUR CHILD HAVE INCURANCE?<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-242\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio field-asfalisi-teknou\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-242\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-242\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row vc-border-b mt-20 mb-20\">\n\t\t\t\t<div class=\"vc-col-12\"><label> DOES YOUR CHILD KNOW YOU'RE COMMUNICATING WITH US? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-gnorizei-to-paidi-tin-epikoinonia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-gnorizei-to-paidi-tin-epikoinonia\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-4\"><label>DOES HE\/SHE HAVE SIBLINGS? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-exei-aderfia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-exei-aderfia\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label>HOW M\u0391\u039d\u03a5: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-posa-aderfia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-posa-aderfia\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label>HOW OLD ARE THEY: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ilikia-aderfon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ilikia-aderfon\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>OCCUPATION OF FATHER: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-epaggelma-patera\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-epaggelma-patera\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>OCCUPATION OF MOTHER: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-epaggelma-miteras\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-epaggelma-miteras\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>WHERE YOU INFORMED ABOUT ANASA? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pou-mathate-tin-anasa\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pou-mathate-tin-anasa\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>WHAT PROBLEM IS THE CHILD FACING?  <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-provlima-paidiou\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-provlima-paidiou\"><\/textarea><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>WHEN DID IT START? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pote-xekinise-to-provlima\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pote-xekinise-to-provlima\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>WEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-varos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-varos\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>HEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ipsos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ipsos\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HOW DOES HE\/SHE LOSE WEIGHT (BY DIETING, EXERCISING OR OTHER WAYS)? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-pos-xanei-ipsos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-pos-xanei-ipsos\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>DOES HE\/SHE USE PILLS? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-kanei-xrisi-xapion\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-kanei-xrisi-xapion\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>DOES HE\/SHE VOMIT? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-kanei-emetous\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-kanei-emetous\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>DOES HE\/SHE HAVE EPISODES OF BINGING? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-epeisodia-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-epeisodia-uperfagias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HOW MANY \u0395PISODES DURING THE DAY?: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-suxnotita-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-suxnotita-uperfagias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>PLEASE GIVE AN EXAMPLE: <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-paradeigma-uperfageias\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-paradeigma-uperfageias\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HAS BEEN OBSERVED BY A PSYCHOLOGIST\/ PSYCHIATRIST IN THE PAST: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-parakolouthisi-psyxologou\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-parakolouthisi-psyxologou\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>ACCEPTED (TO BE COMPLETED BY THE RESPIRATORY SPECIALIST): <span class=\"wpcf7-form-control-wrap\" data-name=\"radio-apodektos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" readonly=\"readonly\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"radio-apodektos\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>AUTHORITY- COMMUNICATION (TO BE COMPLETED BY ANASA'S SPECIALIST): <span class=\"wpcf7-form-control-wrap\" data-name=\"text-armodios-epikoinonia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text vc-field-input vc-field-tel\" readonly=\"readonly\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-armodios-epikoinonia\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<p>I confirm the accuracy and correctness of the above information which I myself\/herself filled in as the parent of my minor child, <span class=\"wpcf7-form-control-wrap\" data-name=\"date-end\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-05-01\" max=\"2026-05-11\" step=\"0\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-05-01\" type=\"date\" name=\"date-end\" \/><\/span> and I sign. <\/p>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-60\">\n\t\t\t\t<div class=\"vc-col-4\">\n\t\t\t\t\t\t<hr>\n\t\t\t\t\t\t<p>Name and Signature<\/p>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-20\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<span>(Note: This completed form will be given to you for signature when you visit KI ANASA on your 1st appointment)<\/span>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-60 mb-40\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-618\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-618\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I have read the <a href=\"https:\/\/www.anasa.com.gr\/en\/notification-statement-of-consent-guardian\/\" target=\"_blank\">Notice<\/a> on the collection and processing of personal data and by submitting my and my minor child's details, I declare my consent.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20\">\n\t\t\t\t<div class=\"vc-col-12\"><p><strong>Subsequently, the clinical team of KI ANASA will receive the completed questionnaire, evaluate it and the Secretariat of KI ANASA will call you to schedule the 1st appointment with a specialist of our Center.<\/strong><\/p><p><strong>\nThank you very much and we will contact you soon!<\/strong><\/p><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><input class=\"wpcf7-form-control has-spinner wpcf7-submit vc-field-submit\" type=\"submit\" value=\"SUBMISSION\" \/><\/div>\n\t\t<\/div>\n\t\t\n\t\t<\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"_links":{"self":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2742"}],"collection":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/comments?post=2742"}],"version-history":[{"count":3,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2742\/revisions"}],"predecessor-version":[{"id":2752,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2742\/revisions\/2752"}],"wp:attachment":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/media?parent=2742"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}