0-3 Overall Appraisal of Functioning

Caregiver's rating of child's functioning across 5 major domains.

General Medical - EPSDT

24 Hour Food Recall

A tool to document the foods that were consumed in the past 24 hours.

General Medical - Healthy Habits/Fitness

ABASI Self-injury Questionnaire

The Alexandria Brothers Assessment of Self-Injury is a tool that helps clinicians to evaluate non-suicidal self injury (NSSI) behaviors in psychiatric patient populations.

Mental Health - General Adult

Abilities and Interests

Caregiver's report of abilities and interests of the child that may be a source of pride in the future.

General Medical - Data Collection

Abnormal Involuntary Movement Scale (AIMS 1)

12-item clinician-rated scale to assess severity of dyskinesias (specifically, orofacial movements and extremity and truncal movements) in patients taking neuroleptic medications.

Mental Health - Abnormal Movements

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

ABAS versions provide a complete assessment of adaptive skills across the life span. Items focus on practical, everyday activities required to function, meet environmental demands, care for oneself, and interact with others effectively and independently.

Mental Health - Educator Administered

Adaptive Behavior Assessment System Third Edition Parent/Primary Caregiver Form (Ages 0-5)*

ABAS versions provide a complete assessment of adaptive skills across the life span. These tools may be useful for evaluating those with developmental delays, autism spectrum disorder, learning disabilities, and sensory or physical impairments.

Mental Health - Preschool Screeners

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

ABAS versions provide a complete assessment of adaptive skills across the life span. These tools may be useful for evaluating those with developmental delays, autism spectrum disorder, learning disabilities, and sensory or physical impairments.

Mental Health - School Aged Screeners

Adaptive Behavior Assessment System Third Edition Teacher/Daycare Provider Form (Ages 2-5) (ABAS-3 (Teacher Ages 2-5))*

ABAS versions provide a complete assessment of adaptive skills across the life span. Items focus on practical, everyday activities required to function, meet environmental demands, care for oneself, and interact with others effectively and independently.

Mental Health - Educator Administered

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

ABAS versions provide a complete assessment of adaptive skills across the life span. Items focus on practical, everyday activities required to function, meet environmental demands, care for oneself, and interact with others effectively and independently.

Mental Health - Educator Administered

ADHD Developmental Intake Form

Intake form for ADHD initial consult. Gathers information about school, family history, behavioral history, and prior medications.

Mental Health - ADHD

ADHD Rating Scale IV - Preschool Version

An 18 item tool to screen for ADHD in preschoolers.

Mental Health - Preschool Screeners

ADHD Rating Scale IV - Preschool Version (Teacher version)

An 18 item tool to screen for ADHD in preschoolers.

Mental Health - Educator Administered

Adjectives to Describe Your Child

Checklist of adjectives to describe the child.

General Medical - Data Collection

Adolescent Health Screen

Adolescent health questionnaire for ages 13 and up that reviews anemia, safety, includes the PHQ-4, substance abuse and STI risk

General Medical - Self Administered

Adolescent Screen - 3 with ASQ/suicide

Three mental health screening tools for adolescents: PHQ-9, PRIUSS, and ASQ.

Mental Health - Depression/Mood Disorders/Suicide

Adolescent Screen - 3 with PHQ-9 + Suicide Items

Three mental health screening tools for adolescents: PHQ-9, PRIUSS, and ASQ.

Mental Health - Depression/Mood Disorders/Suicide

Adolescent Screen - 4 - For waiting room use only

Four mental health screens for teens: PHQ-9, PRIUSS, CRAFFT, and ASQ

Mental Health - Depression/Mood Disorders/Suicide

Adolescent Questionnaire Combined

General Medical - Teen/GAPS

Adolescent Questionnaire Youth

Questionnaire used to gather information from adolescents in attempt to identify additional concerns and risky behaviors.

General Medical - Teen/GAPS

Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Instrument consisting of the 18 DSM-IV-TR criteria for ADHD.

Mental Health - ADHD

Adult Primary Care Screening Tool

A brief tool that screens for anxiety, depression, PTSD, substance use, and domestic violence in adults.

General Medical - Adult

Adult Self-Report for Ages 18-59 (ASR)*

Adults complete the ASR to report their own adaptive functioning, problems, and substance use. The ASR is also valuable for assessing parents of children seen for mental health and family therapy services.

General Medical - Adult

Adverse Childhood Experiences (ACE)

Assesses adults’ adverse experiences in childhood.

General Medical - Social Determinants of Health

Adverse Childhood Experience Questionnaire for Adults

Adverse Childhood Experience Questionnaire for Adults

General Medical - Social Determinants of Health

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

Questionnaire pertaining to the adverse and positive events during the parent's own childhood. This may be used to inform a discussion regarding actionable items the parent may want to repeat or do better in raising their own child.

General Medical - Social Determinants of Health

Adverse Childhood Experiences Questionnaire (ACE-Q) Child Anonymous CYW

Questionnaire about adverse events during childhood. 0-12 years.

General Medical - Social Determinants of Health

Adverse Childhood Experiences Questionnaire (ACE-Q) Child CYW

Questionnaire about adverse events during childhood. 0-12 years.

General Medical - Social Determinants of Health

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

Questionnaire about adverse events during childhood. 12-18 years

General Medical - Social Determinants of Health

Adverse Childhood Experiences Questionnaire (ACE-Q) Teen CYW

Questionnaire about adverse events during childhood. 12-18 years

General Medical - Social Determinants of Health

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

Questionnaire about adverse events during childhood. 12-18 years.

General Medical - Social Determinants of Health

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

Questionnaire about adverse events during childhood. 12-18 years

General Medical - Social Determinants of Health

Ages & Stages Questionnaires®, Third Edition (ASQ®-3) (2 months - 60 months) © 2009 Brookes Publishing Co.

The Ages & Stages Questionnaires® are designed to assess development among infants and children.

Development - Screening

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2) (2 months - 60 months) & ASQ®:SE-2 User’s Guide, Squires et al. © 2015 Brookes Publishing Co.*

Assesses personal and social development in areas including self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people.

Mental Health - Infant Screeners

Alabama Parenting Questionnaire - Short Form APQ-9

Assessment of parenting in research and applied settings. It uses parent and youth ratings for three scales: Positive Parenting, Inconsistent Discipline, and Poor Supervision.

Mental Health - Family/Environment

Alcohol Use Disorders Identification Test—Consumption (AUDIT-C)

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems.

Mental Health - Substance

Anxiety Screen for Adults

A seven item scale with high sensitivity for detecting generalized anxiety disorder and panic disorder.

Mental Health - Anxiety

Anxiety Screen for Adults short version

A two item scale with high sensitivity for detecting generalized anxiety disorder and panic disorder.

Mental Health - Anxiety

Arkansas Lead Screening

From Arkansas Medicaid Managed Care Services

General Medical - EPSDT

ASD PEDS

An Autism Evaluation Tool for Toddlers and Young Children. To be administered only by clinicians. Vanderbilt University Medical Center. Triad.vumc.org

Development - Autism Screening

ASET Symptom Checklist 6+

The ASET Symptom Checklist was designed for children over age 6 or adults with autism. It covers mood, anxiety, attentional and some behavior symptoms that are seen in individuals on the Autism Spectrum.

Development - Autism Screening

Ask Suicide Screening Questions (ASSQ)

Use only in the office waiting room or exam room by clinician administration. This 4-question screening instrument with high sensitivity and negative predictive value, can identify the risk for suicide in teens.

Mental Health - Depression/Mood Disorders/Suicide

Ask Suicide Screening Questions Clinician Form

This 5-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and negative predictive value, can identify the risk for suicide in teens.

Clinician Tools

Asthma Control Parent Perception Rating

Asthma assessment and management

General Medical - Asthma

Asthma History

A tool documenting the patient and family history of asthma.

General Medical - Asthma

Asthma Medications

Asthma assessment and management

General Medical - Asthma

Asthma Medications Without Adherence Questions

This is a brief questionnaire that collects information about the child's prescribed asthma medication regime.

General Medical - Asthma

Asthma Priorities

Asthma assessment and management

General Medical - Asthma

Asthma Trigger Exposure Questionnaire

This is a brief questionnaire asking about common triggers for allergies or asthma including: plant pollen, molds, animals, dust, foods, cockroaches and also smoke. The questionnaire asks what action if any the parent is taking to address the issue.

General Medical - Asthma

Asthma: Asthma Control Test (ACT) for People 12 Years and Older

This 5-item tool screens for possible concerns regarding asthma control.

General Medical - Asthma

Asthma: Childhood Asthma Control Test (ACT) for Children 4 to 11 Years

This 7-item screen screens for possible problems in control of asthma symptoms. The screen includes 4 items to be answered by the child (with adult assistance as needed) and 3 items to be answered by parents.

General Medical - Asthma

Australian Scale for Asperger's Syndrome

Designed to identify behaviours and abilities indicative of Asperger's Syndrome in children during their primary school years (KG-8 grade).

Development - Autism Screening

Autism Quotient 10 Parent Version

A 10 item referral guide for parents to complete about a child aged 4-11 years with suspected autism who does not have a learning disability.

Development - Autism Screening

Autism Quotient 10

A 10 item referral guide for adults with suspected autism who do not have a learning disability.

Development - Autism Screening

Autism Quotient 10 Parent of Teen Version

A 10 item referral guide for parents to complete about a teenager aged 12-15 years old with suspected autism who does not have a learning disability.

Development - Autism Screening

Autoimmune Encephalopathy Clinic Intake Form

General Medical - Data Collection

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

A 9-item/11-item self report screen for Avoidant/Restrictive Food Intake Disorder.

Mental Health - Eating Disorders

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

A 9-item/11-item self report screen for Avoidant/Restrictive Food Intake Disorder.

Mental Health - Eating Disorders

Baby Pediatric Symptom Checklist (BPSC)

A short questionnaire that screens for behavioral problems. It is part of the Survey of well-being of young children.

Mental Health - Infant Screeners

Balanced Measure of Psychological Needs Scale (BMPN)

18 item rating scale for psychological satisfaction. Subscales for relatedness, competence, and autonomy.

Mental Health – General Adult

Barkley Deficits in Executive Functioning Scale-Children and Adolescents

A parent report 70 item rating scale to evaluate executive functioning in daily life activities of children ages 6-17.

Mental Health - ADHD

Barkley Deficits in Executive Functioning Scale— Children and Adolescents Short Form

A parent report 20 item rating scale to screen for executive functioning deficits in daily life activities of children ages 6-17.

Mental Health - ADHD

BEARS Sleep Screening Tool (Adolescent / Parent report)

A single question parent report tool to screen for sleep disordered breathing in adolescents. It is intended to be given in conjunction with the adolescent self report version of the BEARS.

General Medical - Sleep

BEARS Sleep Screening Tool (Adolescent / Self report)

A nine item screen for sleep related illnesses in adolescents.

General Medical - Sleep

BEARS Sleep Screening Tool (Preschool / Parent report)

A short screen for sleep related illnesses in preschool aged children.

General Medical - Sleep

BEARS Sleep Screening Tool (School-aged / Parent report)

An eight item screen for sleep related illnesses in school-aged children.

General Medical - Sleep

BEARS Sleep Screening Tool (School-aged / Self report)

A four item self-report that is used to screen for sleep related illnesses in school-aged children.

General Medical - Sleep

Best and Hardest Parts of Parenting

Checklist for caregiver to endorse best as well as the hardest parts of parenting this child

Mental Health - Parenting

Best Parts of Parenting

Checklist for caregiver to endorse best parts of parenting this child

General Medical - Data Collection

Blood Lead Screening and Healthy Homes Summary

Mississippi lead screen

General Medical - EPSDT

Borderline Symptom List 23 (BSL-23)

Assesses the severity of the Borderline Personality Disorder symptoms.

Mental Health - Borderline

Brenner 'Families in Training'

Questionnaire asks parents a series of questions to assess overall health and fitness habits of a child and their family plus questions about readiness for change.

General Medical - Healthy Habits/Fitness

Brief Early Childhood Screening Assessment w/ Depression

Screener for emotional/behavioral problems in young children, with additional items assessing parent emotional functioning.

Mental Health - Preschool Screeners

Brief Early Childhood Screening Assessment w/ Stress (Brief ECSA w/ Stress)

Screener for emotional/behavioral problems in young children, with additional items assessing parent emotional functioning.

Mental Health - Infant Screeners

Brief Problem Monitor (Parent 6-18; Teacher 6-18; Youth 11-18; Adult 18-59)*

19-item abbreviated version of the 120 diagnostic, very well researched questionnaire, the Child Behavior Checklist for Ages 6 to 18. Evaluates responses to interventions designed to reduce problems and improve adaptive functioning.

Mental Health - School Aged Screeners

Brief Psychiatric Rating Scale

An 18-item clinician rated scale of psychiatric symptoms.

Clinician Tools

Bright Futures Pre-visit Questionnaire© (First-week visit thru 18-21 year visit)* Parent/Child

AAP tools to accompany and support Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition

General Medical - Bright Futures Including Safety

Burlington and Mebane Pediatrics Teen Health Assessment

BP and MP Teen Health Assessment for all teen visits

Adolescent Self-Administered

CADDRA Teacher Assessment Form

CADDRA Teacher Assessment Form. Adapted from Dr Rosemary Tannock's Teacher Telephone Interview.

Educator/Teacher Administered

CAGE-AID

A brief tool that screens for substance use in adults.

Mental Health - Substance

California Pediatric Tuberculosis Risk Assessment

A questionnaire to identify asymptomatic children for latent TB infection

Clinician Tools

Cannabis Use Disorders Identification Test - Revised (CUDIT-R)

The CUDIT-R is a short tool to assess cannabis misuse in the past six months.

Mental Health - Substance

Caregiver Concerns Questionnaire (for children with Autism)

Caregiver Concerns Questionnaire (for children with Autism)

Development - Autism Screening

Caregiver-Teacher Report Form for Ages 1 1/2 - 5 (for use in daycare settings) (CTRF 1 1/2 - 5)*

A tool to assess behavioral issues in daycare settings, including depression, anxiety, autism, ADHD, and opposition.

Educator/Teacher Administered

Child Behavior Checklist for Ages 1 1/2-5; 6-18*

A tool to assess behavioral issues in children ages 6 through 18. A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Teen Administered

CBCL: Youth Self-Report for Ages 11-18*

A tool for adolescents to self-assess their behavioral issues. It is for use with patients who are ages 11 through 18. A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Teen Administered

CEASE Questionnaire

CEASE screens for parental tobacco use and exposure. Proactive referral to the free state quitline, and pharmacologic management of tobacco dependence (NRT patch and gum) are facilitated

General Medical - Social Determinants of Health

CEASE Questionnaire Follow Up

CEASE screens for parental tobacco use and exposure. Proactive referral to the free state quitline, and pharmacologic management of tobacco dependence (NRT patch and gum) are facilitated

General Medical - Social Determinants of Health

Center for Epidemiological Studies Depression Scale for Children (CES-DC)

The Center for Epidemiological Studies Depression Scale for Children is a 20-item self-report depression inventory.

Mental Health - Depression/Mood Disorders/Suicide

CHADIS 0-3: All Domains

Assesses all domains of functioning relevant to infants and toddlers: sleep, feeding, stressful life events, regulation, and mood/anxiety.

Mental Health - Infant Screeners

CHADIS 0-3: Feeding

Questions assessing feeding among infants and toddlers.

Mental Health - Infant Screeners

CHADIS 0-3: Life Events

Assesses potentially stressful events in the child's family.

Mental Health - Infant Screeners

CHADIS 0-3: Regulation

Questions assessing regulation among infants and toddlers.

Mental Health - Infant Screeners

CHADIS 0-3: Sleep

Questions assessing sleep among infants and toddlers. Questionnaire derived from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: Revised Edition (DC: 0-3R; Zero to Three, 2005). Assesses both DC: 0-3R criteria for sleep disorders and general information regarding daily sleep habits.

Mental Health - Infant Screeners

CHADIS 0-3: Worries and Moods

Questions assessing mood and anxiety among infants and toddlers.

Mental Health - Infant Screeners

CHADIS Feedback Questionnaire: Parent Version

Allows parents to provide feedback regarding their use of chadis.

Quality Monitoring/Satisfaction

CHADIS Medicare Annual Wellness Questionnaire

This questionnaire was designed to cover all patient-report topics for a standard Medicare Adult Wellness Visit.

General Medical - Adult

Challenging Behaviors for AZ

Mental Health - School Aged Screeners

Challenging Parts of Parenting

Checklist for parent to endorse most challenging parts of parenting

Mental Health - Parenting

CHAMPS Youth Self-Report

Youth-self-report questionnaire assessing risk behavior including diet, exercise, violence exposure, and sexual behavior.

Mental Health - Teen Administered

Checklist for Autism Spectrum Disorder*

30-item symptom checklist for parent or teacher completion and interview that simplifies autism screening and informs diagnosis.

Development - Autism Diagnostic or Educator/Teacher Administered

Checkup Questionnaire: Nutrition, TB, Social determinants of health

Contains nutrition, TB and social determinants of health questions for assessment of our patient and family risk factors

General Medical - General

Chief Concern for Visit

Inquires about the primary concern for the visit.

General Medical - Data Collection

Child Behavior Checklist for Ages 1 1/2-5*

A tool to assess behavioral issues in children ages 1 1/2 through 5. A wide range of domains are assessed including depression, anxiety, autism, ADHD, and opposition.

Mental Health - Preschool Screeners

Child Behavior Checklist for Ages 1 1/2-5 French Version*

A tool to assess behavioral issues in children ages 1 1/2 through 5. A wide range of domains are assessed including depression, anxiety, autism, ADHD, and opposition.

Mental Health - Preschool Screeners

Child Behavior Checklist for Ages 6-18*

A tool to assess behavioral issues in children ages 6 through 18. A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Diagnostic

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

A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Teen/Parent Administered

Child Behavior Checklist for Ages 6-18 French Version*

A tool to assess behavioral issues in children ages 6 through 18. A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Diagnostic

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

A wide range of domains are assessed including school, social, activities, depression, anxiety, somatic complaints, ADHD, defiance, and conduct.

Mental Health - Teen/Parent Administered

Child Medical History Form

The Child Medical History provides a summary of concerns, diagnoses, services, medical events, tests and medicines that have occurred.

General Medical - Past History

Child Obsessional Compulsive Inventory-Revised Parent Report 10

The Child Obsessional Compulsive Inventory-Revised Parent Report 10 (P-CHOCI-R 10) is a validated short self-report tool to measure the severity of symptoms associated with obsessive-compulsive disorder.

Mental Health - OCD

Child Obsessional Compulsive Inventory-Revised Self Report 10

The Child Obsessional Compulsive Inventory-Revised Self Report 10 (CHOCI-R SR 10) is a validated short self report tool to measure the severity of symptoms associated with obsessional compulsive disorder.

Mental Health - OCD

Child's Reaction to Traumatic Events Scale (CRTES)

A 15 item self-report measure designed to assess psychological responses to stressful life events.

Mental Health - Trauma

Childhood Autism Rating Scale, Second Edition, (High-functioning clinical tool) (CARS2-HF) © 2010 by WESTERN PSYCHOLOGICAL SERVICES*

The CARS helps to identify children (2 years and older with Autism, specifically, distinguishing them from developmentally handicapped children who are not Autistic. In addition, it distinguishes between mid-to-moderate and severe Autism.

Development - Autism Screening

Childhood Autism Rating Scale, Second Edition, (Standard clinical tool) (CARS2-ST) © 2010 by WESTERN PSYCHOLOGICAL SERVICES*

The CARS helps to identify children (2 years and older with Autism, specifically, distinguishing them from developmentally handicapped children who are not Autistic. In addition, it distinguishes between mid-to-moderate and severe Autism.

Development - Autism Screening

Childhood Sleep Questionnaire

This tool combines the BEARS sleep screening questions with items from the Children's Sleep Habits Questionnaire.

General Medical - Sleep

Children Experiencing Homlessness Initial Student Screening Tool

A tool for school nurses to use to assess homelessness risks in children and adolescents.

Educator/School Nurse Administered

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

Five item tool that identifies children with special health care needs.

General Medical - Data Collection

CHOP Introductory Questionnaire

Inquires about prior autism diagnosis, and early intervention participation

General Medical - Clinic Specific Introductory Questionnaires

CIRENE Developmental Questionnaire (0-5 years) (6-18 years)

CIRENE Developmental Questionnaire (6-18 years)

Development - History

Client Satisfaction Questionnaire (CSQ-8)*

The basic purpose of the CSQ-8© scale is to measure and assess consumer satisfaction with health and human services.

Quality Monitoring/Satisfaction

Clinical Global Impression (CGI)

A global rating of illness severity, improvement and response to treatment

Clinician Tools

Clinical Opiate Withdrawal Scale (COWS)

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a clinician.

Clinician Tools

Colorado Pediatric Collaborative Asthma Data Collection Form

A brief tool that gathers data on the treatment and severity of a patient's asthma in the past 6 months.

General Medical - Asthma

Columbia-Suicide Severity Rating Scale - Clinician/Adult/Child/TeenScreen/Recent-with Guidance

Tools includes probes for suicidal ideation, intent, plan, self-injurious behavior, attempts and lethality.

Mental Health - Depression/Mood Disorders/Suicide

Columbia Depression Scale - TO BE COMPLETED BY PARENT

Depression tool about teen that evaluates the Present State (last 4 weeks).

Mental Health - Depression/Mood Disorders/Suicide

Columbia Depression Scale - TO BE COMPLETED BY TEEN

Depression tool about teen that evaluates the Present State (last 4 weeks).

Mental Health - Depression/Mood Disorders/Suicide

Communication Preferences (JCAHO) and Patient Safety Screen

Communication Preferences (JCAHO) and Patient Safety Screen

General Medical - JCAHO Specific

Conflict Tactics Scale - Parent-Child, Short Form

Screens for parental methods of child punishment. The most widely used tool for screening for physical abuse or neglect. This version does not include sexual abuse items.

Mental Health - Family/Environment

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

A tool for caregivers to screen for traumatic experiences in children

Mental Health – Trauma

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

A self report screening tool for trauma in children

Mental Health – Trauma

Conners 4™ - ADHD Index Parent*

This is a 10 item ADHD symptom scale for follow-up care. There are longer diagnostic versions.

Mental Health - ADHD

Conners 4™ - ADHD Index Self*

Assessment of ADHD and Comorbid Disorders in youth aged 6 to 18 years.

Mental Health - ADHD

Conners 4™ - ADHD Index Teacher*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. This is the 10 item form for follow-up monitoring by the child's teacher.

Educator/Teacher Administered

Conners 4™ - Global Index Parent*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. This is the 10 item form for follow-up monitoring.

Mental Health - ADHD

Conners 4™ - Global Index Teacher*

The Conners 3 is designed to assess ADHD and comorbid disorders in children ages 6 to 18. This is the 10 item teacher follow-up version

Educator/Teacher Administered

Conners 4™ - Parent*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. There are 110 item and 45 item versions.

Mental Health - ADHD

Conners 4™ - Parent Short*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. This is the 45 item form called the short form. There is also 110 item and 10 item parent form.

Mental Health - ADHD

Conners 4™ - Self*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. There are forms for parents, teachers, and a self report for teens. It screens for emotional behavioral and academic disorders.

Mental Health - ADHD

Conners 4™ - Self Short*

Self administered 41 item tool for ages 8 -18 for ADHD and co-morbid conditons.

Mental Health - ADHD

Conners 4™ - Teacher*

Assesses ADHD and comorbid disorders in children ages 6 to 18 years of age. It screens for emotional behavioral and academic disorders.

Educator/Teacher Administered

Conners 4™ - Teacher Short*

Assesses ADHD and comorbid disorders in children ages 6 to 18. This is the shorter (45 item) teacher diagnostic version

Educator/Teacher Administered

COVID Self-Checker - CDC for Children 0-18

Screen for children ages 0-18 years who may be experiencing symptoms related to COVID-19

General Health - Data Collection

CRAFFT (Clinician Interview)

Substance abuse screener intended specifically for adolescents. It draws upon adult screening instruments, covers alcohol and other drugs, and calls upon situations that are suited to adolescents.

Clinician Tools

CRAFFT Questionnaire Clinician Version 2.1

The CRAFFT is a substance abuse screener intended specifically for adolescents. It draws upon adult screening instruments, covers alcohol and other drugs, and calls upon situations that are suited to adolescents.

Mental Health - Substance

CRAFFT Questionnaire Self Administered Version 2.1

Substance abuse screener intended specifically for adolescents. It draws upon adult screening instruments, covers alcohol and other drugs, and calls upon situations that are suited to adolescents.

Mental Health - Substance

CRAFFT+N Questionnaire Clinician Version 2.1

The CRAFFT is a brief teen substance abuse screener with this clinician adminstered version. The +N version also includes questions on nicotine use.

Mental Health - Substance

CRAFFT+N Questionnaire Self Administered Version 2.1

The CRAFFT is a brief teen substance abuse screener with this clinician adminstered version. The +N version also includes questions on nicotine use.

Mental Health - Substance

CRAFFT +N +HONC Version 2.1

The CRAFFT+N-HONC inquires about substance use and dependence.

Mental Health - Substance

Demographics-Long

Demographic questions for patients.

Mental Health - Family/Environment

Demographics-Short

Demographic questions to supplement the demographic questions already asked by the DSM-PC

Mental Health - Family/Environment

Depression Anxiety Stress Scale (DASS)

The DASS is a 42-item self report instrument designed to measure the three related negative emotional states of depression, anxiety and tension/stress.

Mental Health – General Adult

Developmental and Behavioral Questionnaire for Children and Adolescents

This form is used to gather pertinent background information for families seeking therapy.

Mental Health - Data Collection

Developmental Coordination Disorder Questionnaire (DCDQ)

The DCDQ is a brief parent questionnaire designed to screen for coordination disorders in children, aged 5 to 15 years.

Development - Motor Development

Developmental History

This tool asks about a number of milestones and if the child has regressed over a three month period. It is of greatest value for children aged two or more being evaluated because of issues related to developmental progress.

Development - History

Developmental Milestones 1-3 months thru 59-65 months

A short questionnaire that is used to track a child's development. It is part of the Survey of Well-being of Young Children.

Development - Screening

DHCS 7098 A - Staying Healthy Assessment 0-6 Months

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 B - Staying Healthy Assessment 7-12 Months

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 C - Staying Healthy Assessment 1-2 Years

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 D - Staying Healthy Assessment 3-4 Years

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 E - Staying Healthy Assessment 5-8 Years

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 F - Staying Healthy Assessment 9-11 Years

Department of Health Care Services' (DHCS's) Individual Health Education Behavior Assessment (IHEBA). In collaboration with Medi-Cal managed care plans Consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 G - Staying Healthy Assessment 12-17 Years (Teen Self Report) v2

The SHA consists of seven age-specific pediatric questionnaires and two adult questionnaires.

General Medical - EPSDT

DHCS 7098 H - Staying Healthy Assessment Adult

The Staying Healthy Assessment (SHA) is the Department of Health Care Services’ (DHCS’s) Individual Health Education Behavior Assessment (IHEBA).

General Medical - EPSDT

DHCS 7098 I - Staying Healthy Assessment Senior

The Staying Healthy Assessment (SHA) is the Department of Health Care Services’ (DHCS’s) Individual Health Education Behavior Assessment (IHEBA).

General Medical - EPSDT

Diagnosis Reporting Tool

A tool to report mental health diagnoses in CHADIS

Mental Health - Diagnostic

Difficulties in Emotional Regulation

DERS is a brief, 36-item, self-report questionnaire designed to assess multiple aspects of emotion dysregulation.

Mental Health - Adult

DIPA ADHD

Diagnostic interview for Attention Deficit Hyperactivity Disorder

Mental Health - Diagnostic

DIPA Anxiety

Diagnostic interview for Separation Anxiety, Social Anxiety, General Anxiety Disorder, Phobias, and Obsessive Compulsive Disorder

Mental Health - Diagnostic

DIPA Bipolar

Diagnostic interview for Bipolar Disorder

Mental Health - Diagnostic

DIPA Conduct Disorder

Diagnostic interview for Conduct Disorder

Mental Health - Diagnostic

DIPA MDD and DMDD

Diagnostic interview for Major Depressive Disorder and Disruptive Mood Dysregulation Disorder

Mental Health - Diagnostic

DIPA ODD

Diagnostic interview for Oppositional Defiant Disorder

Mental Health - Diagnostic

DIPA PTSD

Diagnostic interview for Post Traumatic Stress Disorder

Mental Health - Diagnostic

DIPA RAD/Disinhibited Social Engagement Disorder

Diagnostic interview for Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

Mental Health - Diagnostic

DIPA Sleep Disorders

Diagnostic interview for Sleep Onset Disorder and Night Waking Disorder

Mental Health - Diagnostic

Drug Abuse Screening Test 10 and AUDIT (DAST-10 and AUDIT)*

This tool consists of four parts: 1) DAST 10, 2) AUDIT, 3) consent to participate in the SBIRT study, and 4) demographics questions.

Mental Health – Substance Use

Drug Abuse Screening Test: 10 item version (DAST-10)*

A 10 item screening test for substance abuse. It is a shortened version of the 20 item DAST.

Mental Health – Substance Use

DSM-PC 5 - All modules

Mental Health - School Aged Screeners

DSM-PC 5: Anxiety

Assesses DSM-5 criteria for anxiety disorders; Provides disorder, problem, and variation diagnosis results

Mental Health - Anxiety

DSM-PC 5: Attention and Hyperactivity

Child Mental Assesses DSM-5 criteria for attention and hyperactivity disorders; Provides disorder, problem, and variation diagnosis results

Mental Health - Diagnostic

DSM-PC 5: Concerns

This checklist measure includes 57 items covering symptoms comprehensive of the DSM-5. It can be used alone to determine areas that need further exploration or in combination with CHADIS-DSM cluster modules for determining provisional mental health criteria and diagnoses.

Mental Health - Preschool Screeners

DSM-PC 5: Conduct

Child Mental Assesses DSM-5 criteria for conduct disorders; Provides disorder, problem, and variation diagnosis results

Mental Health - Diagnostic

DSM-PC 5: Mood

Assesses DSM-5 criteria for mood disorders; Provides disorder, problem, and variation diagnosis results.

Mental Health - Depression/Mood Disorders/Suicide

DSM-PC Diagnostic Questionnaire

A series of algorithmic questionnaires which are triggered by parent concerns, based on the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition DSM-IV and DSM-PC

Mental Health - Diagnostic

Early Childhood Screening Assessment (ECSA)

Screener for emotional/behavioral problems in young children, with additional items assessing parent emotional functioning.

Mental Health - Preschool Screeners

Early Childhood Screening Assessment Short Version (Brief ECSA)

Screener for emotional/behavioral problems in young children, with additional items assessing parent emotional functioning.

Mental Health - Preschool Screeners

Eating Attitudes Test (EAT 26)

A 26 item test to assess the risk of eating disorders.

Mental Health - Eating Disorders

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is one of the most widely-used tools for the assessment of postpartum depression.

General Medical - Social Determinants of Health

Edinburgh Postnatal Depression Scale, Co-Caregiver

This tool assesses post-partum depression for the co-caregiver.

General Medical - Social Determinants of Health

Emerging Adults Developmental Milestones Questionnaire

Mental Health - General Adult

Emotion Dysregulation Inventory

a caregiver-report questionnaire designed to capture emotional distress and problems with emotion regulation without requiring verbal information.

Mental Health - General Adult

Environmental Triggers and Smoke Exposure Questionnaire

A tool to gather information regarding environmental triggers of breathing problems and smoke exposure.

General Medical - Asthma

EPSDT-Anemia Screen

Virginia EPSDT-required questions for anemia screening

General Medical - EPSDT

EPSDT - AZ (1-24 mo)(3yr-12yr)

An EPSDT created by the state of Arizona which is intended to be completed by a clinician. It contains sections for Medications, Allergies, Family history, Parental concerns, Oral health, Nutrition, Developmental surveillance, Anticipatory guidance, Social-Emotional health, Labs, Vaccines, and Referrals.

Clinician Tools

EPSDT - TX (Health Risk)

Screens for health risks including exposure to HIV, low fluoride, smoker, substance abuse and person w/ low immunity/chemotherapy, live vaccine.

General Medical - EPSDT

EPSDT (Health Risk)

Screens for health risks including exposure to HIV, TB, lead, low fluoride, smoker, substance abuse and person w/ low immunity/chemotherapy, live vaccine.

General Medical - EPSDT

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

Screens for health risks including exposure to HIV, TB, lead, low fluoride, smoker, and substance abuse.

General Medical - EPSDT

EPSDT Fluoride v2.0 -Maryland

General Medical - EPSDT

EPSDT - Full Version Maryland

General Medical - EPSDT