Pediatric Questionnaires | CHADIS
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Preschool Kids

Child/Adolescent Screening Questionnaires & Diagnostic Tools

Development - Autism Diagnostic

Development - Autism Screening

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Development - Feeding

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Development - History

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Development - Language

  • Infant Development Inventory: Language Domain

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Development - Motor

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Development - Screening

General Medical - Asthma

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General Medical - Bright Futures Including Safety

  • Bright Futures Pre-visit Questionnaires© (First-week visit - 18-21 year visit)* Copyright © 2019 American Academy of Pediatrics. All rights reserved.

General Medical - Safety Tools Used for Bright Futures Focus

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General Medical - Clinic Specific Introductory Questionnaires

  • CHOP Introductory Questionnaire

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General Medical - Data Collection

  • Abilities and Interests 

  • Adjectives to Describe Your Child 

  • Adolescent Health Screen

  • Adverse Childhood Experiences and Positive Childhood Experiences (ACE/PCE)

  • Advocate Medical Group Intro 

  • Autoimmune Encephalopathy Clinic Intake For

  • Best Parts of Parenting

  • CDC Coronavirus Self-Checker for Children 0-18

  • Challenging Parts of Parenting

  • Chief Concern for Visit 

  • Child and Family Questionnaire

  • Children with Special Health Care Needs Screener© (CSHCN Screener©) 

  • Communication Preferences (JCAHO) and Patient Safety Screen

  • Developmental and Behavioral Questionnaire for Children and Adolescents

  • DHCS 7098 A - Staying Healthy Assessment 0-6 Months (SHA 0-6 Months)

  • DHCS 7098 B - Staying Healthy Assessment 7-12 Months (SHA 7-12 Months)

  • DHCS 7098 C - Staying Healthy Assessment 1-2 Years (SHA 1-2 Years)

  • DHCS 7098 D - Staying Healthy Assessment 3-4 Years (SHA 3-4 Years)

  • DHCS 7098 E - Staying Healthy Assessment 5-8 Years (SHA 5-8 Years)

  • DHCS 7098 F - Staying Healthy Assessment 9-11 Years (SHA 9-11 Years)

  • DHCS 7098 G - Staying Healthy Assessment 12-17 Years (Teen Self Report) (SHA 12-17 Years)

  • Goals for Change

  • Initial Patient History

  • Legacy

  • Medication Side Effects (Parent)

  • Medication Side Effects (Teacher)

  • Ogden Patient Demographics Available in English Experimental

  • One year injury history

  • Parent’s Adolescent Health Screen

  • Parent's Concerns

  • Patient Annual Update

  • ​Patient Demographics - General

  • Positive Childhood Experiences (PCE)

  • Pre Appointment COVID Screener

  • Review of Systems 

  • Safety Checklist: 1 Week through 9 Months

  • Safety Checklist: Newborn

  • Safety Checklist: Prenatal

  • The Child Health Center Well Visit Form 0-5 Months

  • Visit Introduction

  • Visit Priorities 

  • Visit Priorities and Best and Hardest Parts of Parenting 

  • Visit Priorities, Best and Hardest Parts of Parenting, and Review of Systems

  • Visit Priorities, Best and Hardest Parts of Parenting, ROS, and Chronic Conditions 

  • Visit Priorities, Chronic Conditions, and Best and Hardest Parts of Parenting 

  • Visit Priorities with Chronic Condition

 

General Medical - EPSDT

  • DHCS 7098 A - Staying Healthy Assessment 0-6 Months (SHA 0-6 Months) 

  • DHCS 7098 B - Staying Healthy Assessment 7-12 Months (SHA 7-12 Months)

  • DHCS 7098 C - Staying Healthy Assessment 1-2 Years (SHA 1-2 Years) 

  • DHCS 7098 D - Staying Healthy Assessment 3-4 Years (SHA 3-4 Years) 

  • DHCS 7098 E - Staying Healthy Assessment 5-8 Years (SHA 5-8 Years) 

  • DHCS 7098 F - Staying Healthy Assessment 9-11 Years (SHA 9-11 Years) 

  • DHCS 7098 G - Staying Healthy Assessment 12-17 Years (Teen Self Report) (SHA 12-17 Years) 

  • EPSDT-Anemia Screen 

  • EPSTD - Arizona (1 mo - 24 mo)

  • EPSDT Fluoride v2.0 -Maryland

  • EPSDT - Full Version Maryland

  • EPSDT (Health Risk) 

  • EPSDT (Health Risk): without questions on HIV or chemotherapy (EPSDT) 

  • EPSDT - Heart Risk - Maryland

  • EPSDT-High Cholesterol Screen 

  • EPSDT-High Cholesterol Screen: hereditary risk factors only 

  • EPSDT IVR

  • EPSDT Lead Screening – Arkansas (Arkansas Lead Screening) 

  • EPSDT-TB Screen

  • EPSDT - TX (Health Risk) 

  • Lead Questionnaire - TX - No Opt-out 

  • EPSDT-VA-Lead Screen 

  • HCY Lead Risk Assessment Guide- Missouri 

  • Illinois Dept. of Public Health: Child lead risk 

  • Lead and Tuberculosis Exposure Screening

  • Lead Exposure Risk Assessment Questionnaire for Children (BCHP)

  • Lead Risk Assessment – Rhode Island ​

  • Lead Screening Questionnaire - TX 

  • Maryland Healthy Kids Preventive Screen - Anemia/STI for Child/Teen Completion 

  • Maryland Healthy Kids Preventive Screen - Lead/TB/CVD for Adult Completion 

  • Maryland Healthy Kids Preventive Screen - Short Version

  • MD EPSDT

  • MD EPSDT - Fluoride 

  • MD EPSDT - Heart Disease

  • MD EPSDT - Lead

  • MD EPSDT - Tuberculosis

  • Pediatric TB Risk Assessment Form - Illinois 

  • Tennessee Tuberculosis Screening Evaluation 

  • Tuberculosis Risk Assessment (BCHP)

  • Tuberculosis Screening Questionnaire - TX
     

General Medical - Family History

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General Medical - General Medical

  • Checkup Questionnaire: Nutrition, TB, Social Determinants of Health

  • Hooked on Nicotine Checklist

  • ​​Safety Checklist: Newborn Safety Checklist

  • Safety Checklist: Prenatal

  • Safety Checklist: 1 Week through 10.5 Months

  • Safety Checklist: 10.5 Months through 4 Years

  • ​Safety Checklist: 5-10 Years

  • Sexuality and Gender Questionnaire

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General Medical - Healthy Habits/Fitness

  • 24 Hour Food Recall

  • Brenner 'Families in Training' (FIT) 

  • Fit Kid Healthy Habits Questionnaire 

  • Health Habits Questionnaire Ages 10+

  • Obesity Consult General Intake Form

  • Oral Risk Assessment Tool

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General Medical - Medical Home Specific

  • Child Medical History 

  • Children with Special Health Care Needs Screener© (CSHCN Screener©)

  • Communication Preferences (JCAHO) and Patient Safety Screen

  • Medical Home Survey

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General Medical - Past History

  • Medical Home Survey

  • National Center for Medical Home Implementation

  • Pregnancy and Perinatal History
 
 

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General Medical - Sleep

General Medical - Social Determinants of Health

General Medical - Special Health Care Needs

  • Abnormal Involuntary Movement Scale (AIMS 1)

  • Kennedy Krieger Independence Scales - Spina Bifida Version (KKIS-SB)

  • Life Clinic Neuro-Behavioral Questionnaire

  • Transition Readiness Assessment Questionnaire (TRAQ) 

  • World Health Organization Disability Assessment Schedule 2.0 Proxy 12-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Proxy 36-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Self 12-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Self 36-item (WHODAS)

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General Medical - Sports

  • MHSA Confidential Athletic Pre-participation Physical Exam (Sports Physical)

  • Sport Concussion Assessment Tool 2: Symptom Evaluation (SCAT2: Symptom Evaluation) 

  • Sport Concussion Assessment Tool – 3rd ed: Parent symptom evaluation for patients 5 to 12 years old (SCAT3- Parent report)
 

  • Sport Concussion Assessment Tool – 3rd ed: Self-administered background and symptom evaluation for patients 13+ (SCAT3: Self-report) 

  • Sport Concussion Assessment Tool – 3rd ed: Self-administered symptom evaluation for patients 5 to 12 years old (Child-SCAT3- Self-report)

  • Sport Concussion Assessment Tool ™ - 6 Child Immediate Assessment /Neuro Screen

  • Sport Concussion Assessment Tool ™ - 6 Child Athlete Information and Concussion History

  • ​Sport Concussion Assessment Tool ™ - 6 Child Off-Field Assessment

  • Sports Participation Questionnaire (Illinois) 

  • Sports Participation Questionnaire (General) Available in English

  • Sports Physical Clinical Tool

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General Medical - Teen/GAPS

  • Adolescent Questionnaire Combined

  • Adolescent Questionnaire Youth

  • BEARS Sleep Screening Tool (Adolescent / Self-report) 

  • Goals Questionnaire

  • Transition Readiness Assessment Questionnaire (TRAQ)​

  • Transition Readiness Assessment Questionnaire - 23-item version (TRAQ)

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General Medical - Vaccine Information/Consent

  • Influenza Vaccine Consent and Screening Form

  • Influenza Vaccine Consent and Screening Form (Revised without intranasal) 

  • Screening Checklist for Contraindications to Vaccines for Children and Teens
     

Mental Health - ADHD

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  • ADHD Developmental Intake Form 

  • ADHD Rating Scale IV - Preschool Version

  • Barkley Deficits in Executive Functioning Scale-Children and Adolescents

  • CADDRA Teacher Assessment Form Available in English, French (Canada)

  • Conners 4   * 

  • Goals for Change 

  • Goals Questionnaire 

  • Medication Questionnaire 

  • Medication Side Effects (Parent)

  • Medication Side Effects (Teacher)

  • Pictorial Pediatric Symptom Checklist 35-item

  • Pictorial Pediatric Symptom Checklist 35-item Youth Report

  • School Intervention Questionnaire

  • Teacher's Report Form for Ages 6-18 (TRF 6-18)

  • Vanderbilt Follow-Up Parent Informant

  • Vanderbilt Follow-Up Parent Informant (with Medication Supplement)

  • Vanderbilt Follow-Up Teacher Informant

  • Vanderbilt Follow-Up Teacher Informant (with Medication Supplement) 

  • Vanderbilt Initial Parent Informant

  • Vanderbilt Initial Parent Informant (with Medication Supplements)

  • Vanderbilt Initial Teacher Informant

  • Vanderbilt Initial Teacher Informant (with Medication Supplement)

  • Weiss ADHD Co-morbid Health Screen (WACS)
     

Mental Health - Abnormal Movements

Mental Health - Anxiety

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Mental Health - Depression/Mood Disorders/Suicide

 

Mental Health - Diagnostic

 

Mental Health - Eating Disorders

  • Avoidant/Restrictive Food Intake Disorder Screen (9-item/11-item) Child version (ARFID)

  • Avoidant/Restrictive Food Intake Disorder Screen (9-item/11-item) Parent version (ARFID)

  • Eating Attitudes Test (EAT 26)

  • SCOFF 
     

Mental Health - Educator/Teacher Administered

 

Mental Health - Family/Environment

 

Mental Health - Infant Screeners

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Mental Health - OCD

  • Child Obsessional Compulsive Inventory-Revised Parent Report 10

  • Child Obsessional Compulsive Inventory-Revised Self Report 10

  • ​Obsessive Compulsive Inventory- Child Version (OCI-CV)

 

Mental Health - Preschool Screeners

 

Mental Health - School Aged Screeners

  • Adaptive Behavior Assessment System Third Edition Parent Form (Ages 5-21) (ABAS-3)*

  • Brief Problem Monitor (Parent 6-18; Teacher 6-18; Youth 11-18)*

  • CHADIS DSM 5 Questionnaire (DSM-PC 5 - All modules)

  • Challenging Behaviors for AZ

  • Child Behavior Checklist for Ages 6-18 (CBCL 6-18)* 

  • Child Behavior Checklist for Ages 6-18 French Version (CBCL 6-18)*

  • Children’s Affective Lability Scale (CALS)

  • Conners 3™ - ADHD Index Parent*

  • Conners 3™ - Global Index Parent*

  • Conners 3™ - Parent*

  • Conners 3™ - Parent Short*

  • Difficulties in Emotion Regulation Scale (DERS)

  • DSM-PC5 ADHD

  • DSM-PC5 Anxiety

  • DSM-PC 5: Concerns

  • DSM-PC5 Conduct

  • DSM-PC5 Mood

  • Mood and Feelings Questionnaire: Child Self-Report Long Version

  • Mood and Feelings Questionnaire: Child Self-Report Short Version

  • Mood and Feelings Questionnaire: Parent Self-Report Long Version

  • Mood and Feelings Questionnaire: Parent Self-Report Short Version

  • Pediatric Symptom Checklist (PSC-17)

  • Pediatric Symptom Checklist (PSC-35)

  • Pictorial Pediatric Symptom Checklist 17-item Parent Version

  • Problem Behavior Checklist 

  • Strengths and Difficulties Questionnaire© (SDQ) 4-10*

  • Strengths and Difficulties Questionnaire Functional Assessment©*

  • Weiss ADHD Comorbid Health Screen (WACS)

  • Weiss Functional Impairment Rating Scale – Parent Report (WFIRS-P)

  • Weiss Functional Impairment Rating Scale – Parent Report averages (WFIRS-P)

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Mental Health - Social Skills

  • Pictorial Pediatric Symptom Checklist 17-item Youth Report

  • Self-Description Inventory 

  • Social Skills Inventory 

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Mental Health - Substance

 

Mental Health - Teen Administered

 

Mental Health - Teen/Parent Administered

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Mental Health - Trauma

  • Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report (Anonymous) CYW (ACE-Q Teen Self-Report (Anonymous) CYW)

  • Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report CYW (ACE-Q Teen Self-Report CYW)

  • Child's Reaction to Traumatic Events Scale (CRTES)

  • Connecticut Trauma Screener - Caregiver Report (CTS - Caregiver Report)

  • Connecticut Trauma Screener - Child Report (CTS - Child Report)

  • PC-PTSD

  • Pediatric Traumatic Stress Screening Tool (6-10) ©2020 Intermountain Healthcare

  • ​Pediatric Traumatic Stress Screening Tool (11+)

  • PTSD Checklist for DSM 5 with Life Events Checklist for DSM-5 (PCL-5 with LEC)
 

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Clinician Tools

  • Ask Suicide Screening Questions (ASQ) 

  • CRAFFT (Clinician Interview)

  • CRAFFT+N Questionnaire Clinician Version 2.1 (CRAFFT+N Clinician)

  • Clinical Global Impression (CGI)

  • Physical and Neurological Examination for Subtle Signs (PANESS)

  • Sport Concussion Assessment Tool – 3rd ed: Clinician tool for patients 5 to12 years old (Child-SCAT3- Clinician tool for 5-12 years) 

  • Sport Concussion Assessment Tool – 3rd ed: Clinician tool for patients 13 years and older (SCAT3: Clinician tool 13+ years ) 

  • Sports Physical Clinical Tool 

  • Theory of Mind
     

Consent

  • Exchange of Information Consent for ADHD Care 

  • Pre Camp Form

 

Quality Monitoring/Satisfaction

  • CHADIS Feedback Questionnaire: Parent Version ​

  • Hampton Pediatrics Patient Satisfaction Survey

  • Parent's View of Child's Health Care

  • Pro-PHDS 3-9 Months 

  • Pro-PHDS 10-18 Months 

  • Pro-PHDS 19-48 Months 

  • Service Provider Questionnaire

  • Session Alliance Inventory (Patient Version)

  • Treatment Acceptability Rating Form (TAR-F)

  • Working Alliance Inventory - Short Revised (WAI-SR) Available in English Experimental

* These questionnaires may have an additional cost associated with them. Ask your account manager or sales representative for details.

 

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