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