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Title | Description | Category |
|---|---|---|
EPSDT - Heart Risk - Maryland | General Medical - EPSDT | |
EPSDT IVR | Items assessing Maryland EPSDT criteria for lead poisoning risk, cholesterol/heart disease risk, and TB risk. | General Medical - EPSDT |
EPSDT Lead Screening - Arkansas | From Arkansas Medicaid Managed Care Services | General Medical - EPSDT |
EPSDT-High Cholesterol Screen | Virginia EPSDT-required questions for high cholesterol screening | General Medical - EPSDT |
EPSDT-High Cholesterol Screen: hereditary risk factors only | A version of the Virginia EPSDT which only includes the questions relating to hereditary risk factors. | General Medical - EPSDT |
EPSDT-TB Screen | Virginia EPSDT-required questions for tuberculosis (TB) screening | General Medical - EPSDT |
EPSDT-VA-Lead Screen | Virginia EPSDT-required questions for lead exposure/poisoning screening | General Medical - EPSDT |
Exchange of Information Consent for ADHD Care | Exchange of Information Consent | Consent |
Falls Risk Assessment Tool (FRAT) | A brief tool to assess of falls risk in older people. | Clinician Tools |
Family Assessment of Safety and Stress Plus Barriers (FASS Plus) | Screens for common psychosocial problems facing many families (parental depression, alcohol and substance abuse, domestic violence, major stress, and food insecurity). | General Medical - Social Determinants of Health |
Family Cardiac History | Questions assessing history of cardiac problems in child's family. | General Medical - Family History |
Family Demographics | Gathers demographic information pertaining to the child and respondent for research. Questions cover ethnicity, healthcare coverage, education, marital status, household income, and number of children in the home. | Mental Health - Family/Environment |
Family Medical History | Checklist of medical conditions for which there is a history in the patient's family. Includes specified mental and physical health issues including Celiac Disease, Cerebral Palsy, COPD, Obsessive Compulsive Disorder, Panic Attacks. | General Medical - Family History |
Family Questions | A short questionnaire screening for social and environmental risks, including smoking, substance abuse, and lack of food. It is part of the Survey of well-being of young children. | Mental Health - Family/Environment |
First Visit Questionnaire | Intake form to be used for a developmental behavioral pediatric consult. It gathers demographic information as well a history related to pregnancy and birth, medical conditions, family, education, development, and social life. | Development - Autism Screening |
First Year Inventory | A 25 item developmental inventory for the first year. | Development - Autism Screening |
Fit Kid Healthy Habits Questionnaire | Healthy eating and weight management questionnaire | General Medical - Healthy Habits/Fitness |
Generalized Anxiety Disorder scale (GAD-7) V2 | A seven item scale with high sensitivity for detecting generalized anxiety disorder and panic disorder. | Mental Health - Anxiety |
Generalized Anxiety Disorder scale 2 (GAD-2) | A two item scale with high sensitivity for detecting generalized anxiety disorder and panic disorder. | Mental Health - Anxiety |
Generalized Self-Efficacy Scale (GSES) | It assesses the strength of an individual's belief in his or her own ability to respond to novel or difficult situations and to deal with any associated obstacles or setbacks. | General Medical - Adult |
Generic Referral Follow-Up Questionnaire | Administered to patients to track whether they have received a referred service and the factors that affected the outcome of the referral. | General Health - General |
Goals and Strengths | Goals and Strengths is a questionnaire that elicits a teen or young adult's perception of their short and long term general life goals. | Adolescent Self-Administered |
Goals for Change | A tool to assist parents of children with ADHD to help them make changes and get the kind of help they need. | Mental Health - ADHD |
Goals Questionnaire | Two items assessing negotiated target goals for the clinician. | Mental Health - ADHD |
Goals Questionnaire for Yourself | Two items assessing negotiated target goals for the clinician about the parent. | Mental Health - Parenting |
GPRA Behavioral Health Form Client Facing | GPRA Behavioral Health Form. Sections C, D, E, G. To be taken by the subject, as opposed to administered by a staff member. | Mental Health - Substance |
GPRA Behavioral Health Form Staff Facing | GPRA Behavioral Health Form. Section F. To be administered by a staff member. | Mental Health - Substance |
GPRA Office Form | This tool consists of part of section A. If the SBIRT is positive then section B is presented, which is the substance use section. It concludes with the patient type. | Mental Health - Substance |
Guidance Topics | Guidance topics to be covered in the context of the visit, as recommended by the AAP's Bright Futures Guidelines. Topics include dental care, media usage, use of interim medical services, and family practices around reading to the child. | General Medical - Bright Futures Compliant |
Guidelines for Adolescent Preventive Screening: Middle-Older Adolescent Questionnaire | Self-report tool gathering information about middle-older adolescents aged 17-21 years. | General Medical - Teen/GAPS |
Guidelines for Adolescent Preventive Services: Parent/Guardian Questionnaire | The GAPS Parent/Guardian Questionnaire collects information related to an adolescents overall well-being. | General Medical - Teen/GAPS |
Guidelines for Adolescent Preventive Services: Younger Adolescent Questionnaire | Self-report questionnaire that gathers information on younger adolescents aged 12-16 years. | General Medical - Teen/GAPS |
HCY Lead Risk Assessment Guide- Missouri | This tool assesses a child's risk of exposure to lead. | General Medical - EPSDT |
HEADSS | A psychosocial interview for adolescents. Home, Education, Activities, Drugs, Sexuality and Suicide. In this version the drugs and suicide questions are not asked. | Mental Health - Teen Administered |
HEADSS (without drugs or suicide items) | A psychosocial interview for adolescents. It is an acronym: Home, Education, Activities, Drugs, Sexuality and Suicide. In this version the drugs and suicide questions are not asked. | Mental Health - Teen Administered |
Health Leads Social Needs Screener | A comprehensive blueprint for health systems seeking to identify and screen patients for adverse social determinants of health. | General Medical - Social Determinants of Health |
Health Screening - SoDH | Simple 11 item screen for Social Determinants of Health including insecurity in food, housing, transportation plus intimate partner violence and questions about urgency and desire for help. | General Medical - Social Determinants of Health |
HealthySteps Family Needs Questionnaire | The HealthySteps Family Needs Questionnaire collects information about SDoH needs including food, transportation, housing, medical access, and urgent needs. | General Medical - Social Determinants of Health |
Healthy Habits Questionnaire Ages 10+ | Current healthy eating, media use, and exercise status with option for family commitments for future improvements | General Medical - Healthy Habits/Fitness |
HIBOU | For screening sleep problems in children and adolescents (2-17 years old). | General Medical - Sleep |
HIBOU: (FOR PRESENTATION IN FRENCH ONLY) For screening sleep problems in children and adolescents (2-17 years old) | For screening sleep problems in children and adolescents (2-17 years old). | General Medical - Sleep |
Home and School Environment (Social History) | Child's social history including home and school environment details | Mental Health - Family/Environment |
Hooked on Nicotine Checklist | Adding the 10 item HONC to routine adolescent health examinations, health classes, and prevention programs may make adolescents more aware of their symptoms of Nicotine Dependence and enable intervention before it progresses.
| General Medical – General |
Hurt, insulted, Threatened with Harm, and Screamed (HiTS) | A domestic violence screening tool | General Medical - Social Determinants of Health |
Hurt, insulted, Threatened with Harm, and Screamed - Partner Version (HiTS-P) | A domestic violence screening tool | General Medical - Social Determinants of Health |
ICP Asthma Data Collection Form (original and revised) | Gathers data on the treatment and severity of a patient's asthma in the past 6 months, as well as information about exercise, triggers, environmental history, past medical history, and family history. | General Medical - Asthma |
IDEA: Inventory of the Dimensions of Emerging Adulthood | It was designed only for research purposes, to give an indication of the extent to which individuals viewed their own attitudes, behaviors, and circumstances as matching those proposed in Arnett's theory of emerging adulthood. | Mental Health - General Adult |
Illinois Dept. of Public Health: Child Lead Risk | State of Illinois, Dept. of Public Health childhood lead risk assessment questionnaire: Brief screen for risk factors for lead poisoning in children 6 months to 6 years. | General Medical - EPSDT |
Infant Development Inventory: All Domains | Screener assessing developmental delay across five domains: social, gross motor, fine motor, self help and language. | Development - Screening |
Infant Development Inventory: Fine Motor | Screener assessing developmental delay in the fine motor domain. | Development - Screening |
Infant Development Inventory: Gross Motor | Screener assessing developmental delay in the gross motor domain. | Development - Screening |
Infant Development Inventory: Language | Screener assessing developmental delay in the language domain. | Development - Screening |
Infant Development Inventory: Self-help | Screener assessing developmental delay in the self help domain. | Development - Screening |
Infant Development Inventory: Social | Screener assessing developmental delay in the social domain. | Development - Screening |
Influenza Vaccine Consent and Screening Form | The influenza vaccine consent and screening form helps clinical staff determine which type of flu vaccine a child should get and if the child should get 1 or 2 doses. | General Medical - Vaccine Information/Consent |
Influenza Vaccine Consent and Screening Form (Revised without intranasal) | The influenza vaccine consent and screening form helps clinical staff determine which type of flu vaccine a child should get and if the child should get 1 or 2 doses. | General Medical - Vaccine Information/Consent |
Influenza Vaccine Consent and Screening Form for Adults | The influenza vaccine consent and screening form helps clinical staff determine which type of flu vaccine a patient should get and if the patient should get 1 or 2 doses. | General Medical - Vaccine Information/Consent |
Influenza Vaccine Consent and Screening Form for Adults (Revised without intranasal) | The influenza vaccine consent and screening form helps clinical staff determine which type of flu vaccine a patient should get and if the patient should get 1 or 2 doses. | General Medical - Vaccine Information/Consent |
Initial Parent History | Initial Parent History, to be used for all new patients. | General Medical - Data Collection |
International Prostate Symptom Score (IPSS) | Eight-question written screening tool used to screen for, rapidly diagnose, track the symptoms of, and suggest management of the symptoms of benign prostatic hyperplasia (BPH). | General Medical - Adult |
Kennedy Krieger Independence Scales - Spina Bifida Version | Spina Bifida Version | General Medical - Special Health Care Needs |
KIMS Kentucky Inventory of Mindfulness Skills | The KIMS is a 39-item self-report inventory used to assess mindfulness skills. | Mental Health - General Adult |
Kutcher Adolescent Depression Screen (KADS) | 6-item self-report scale that was designed specifically to diagnose and assess the severity of adolescent depression. | Mental Health - Depression/Mood Disorders/Suicide |
Launch Weekly Assessment Measure | A combination of two validated questionnaires, the GAD-7 and the PHQ-9, with an additional question regarding overall quality of life. | Mental Health - Depression/Mood Disorders/Suicide |
Lead and Tuberculosis Exposure Screening | Lead Poisoning and Tuberculosis Risk Assessment for the state of Florida | General Medical - EPSDT |
Lead and TB Screener - General | To identify children who need to be tested for lead exposure. | General Medical - EPSDT |
Lead Exposure Risk Assessment Questionnaire for Children (BCHP) | A lead risk assessment tool | General Medical - EPSDT |
Lead Risk Assessment - Rhode Island | A lead risk assessment tool | General Medical - EPSDT |
Lead Screener - General | General Medical - EPSDT | |
Lead Screening Questionnaire - TX | A seven item screening questionnaire for lead testing. | General Medical - EPSDT |
Lead Questionnaire - TX - No Opt-out | To identify children who need to be tested for lead exposure. | General Medical - EPSDT |
Legacy | Assesses characteristics the parent sees in their child, as well as characteristics they would like to see. | General Medical - Data Collection |
Level I Assessment for Children with Tics and/or Tourette Syndrome - Dynamic Version | Level I assessment for children with tics and/or Tourette syndrome. | Mental Health - Abnormal Movements |
Life Clinic Neuro-Behavioral Questionnaire | A screener for emotional and behavioral problems in cancer patients that was developed by the Kennedy Krieger Institute. | General Medical - Special Health Care Needs |
Maryland Healthy Kids Preventive Screen - Anemia/STI for Child/Teen Completion | Health risk factors as required by EPSDT in Maryland. There are two parts, one for parents of a child 0-20 covering lead, TB and cardiovascular risk. The other one is for teens 11-20 and covers anemia and STI/HIV risk. | General Medical - EPSDT |
Maryland Healthy Kids Preventive Screen - Lead/TB/CVD for Adult Completion | Health risk factors as required by EPSDT in Maryland. There are two parts, one for parents of a child 0-20 covering lead, TB and cardiovascular risk. The other one is for teens 11-20 and covers anemia and STI/HIV risk. | General Medical - EPSDT |
Maryland Healthy Kids Preventive Screen | Provider forms that are recommended/required for use when doing preventive visits per the Healthy Kids Guidelines. | General Medical - EPSDT |
Maryland Healthy Kids Preventive Screen - Short Version | Health risk factors as required by EPSDT in Maryland. | General Medical - EPSDT |
MB CDI: Words and Gestures English; French Version | The MacArthur-Bates Communicative Development Inventories (CDIs) provide a systematic way for professionals to use parents as informants regarding their child’s language for screening and developing a prognosis for children with language delays. | Development - Autism Screening |
MacArthur-Bates Communicative Development Inventory: Words and Sentences | The CDIs are parent-report measures designed to evaluate the communicative skills of young, typically developing children from their “early signs of comprehension, ... to the expansion of early vocabulary and the beginnings of grammar.” | Development - Autism Screening |
MB-CDI: Words and Sentences with shortform vocabulary with alternative language questions in French | A version of the MacArthur-Bates CDI: Words and Sentences for use in research. It replaces the vocabulary checklist with the Short Form II B and modifies the response options for multi-lingual children. | Development - Autism Screening |
McMaster Family Assessment Device, General | A general assessment of family functioning. The measure includes 12 statements about family communication and support. | Mental Health - Family/Environment |
MD EPSDT | Items assessing Maryland EPSDT criteria for lead poisoning risk, cholesterol/heart disease risk, and TB risk. | General Medical - EPSDT |
MD EPSDT - Fluoride | Items assessing Maryland EPSDT criteria for fluoride risk. | General Medical - EPSDT |
MD EPSDT - Heart Disease | These questions are recommended/required for use of the providers when doing preventive visits per Healthy Kids Program guidelines in Maryland for cardiovascular health risk. | General Medical - EPSDT |
MD EPSDT - Lead | These questions are recommended/required for use of the providers when doing preventive visits per Healthy Kids Program guidelines in Maryland for lead risk. | General Medical - EPSDT |
MD EPSDT - Tuberculosis | These questions are recommended/required for use of the providers when doing preventive visits per Healthy Kids Program guidelines in Maryland for tuberculosis risk. | General Medical - EPSDT |
Medical Home Survey | A brief tool that gathers demographic data, information about safety, food insecurity, housing, transportation, and other needs of the family. | General Medical - Medical Home Specific |
Medication Side Effects (Parent) | Medication side effects items adapted from the NICHQ Vanderbilt Assessment. | Mental Health - ADHD |
Medication Side Effects (Teacher) | Medication side effects items adapted from the NICHQ Vanderbilt Assessment. | Educator/Teacher Administered |
Medication Questionnaire | Items assessing medications, dosages, and compliance. | General Medical - Data Collection |
MHSA Confidential Athletic Pre-participation Physical Exam (Sports Physical) | To gather patient health history information including medication, allergies, physical questions. To support a pre-participation evaluation, or sports physical meant to help maintain the health and safety of athletes. | General Medical - Sports |
The Mini-Cog© | A brief clinician screen for dementia. | Clinician Tools |
Modified Checklist for Autism in Toddlers Revised (M-CHAT-R) | A 20-item parent-report checklist that screens for ASD. | Development - Autism Screening |
Modified Checklist for Autism in Toddlers Revised (M-CHAT-R) Follow-Up Interview | This interview is to be used by clinicians to help rule out a diagnosis of autism by reviewing the original respondent's responses to the M-CHAT-R® questionnaire. | Development - Autism Screening |
The Modified Overt Aggression Scale | A clinician rating scale for aggressive behavior over the past week. | Clinician Tools |
Montreal Children's Hospital Feeding Scale (MCH-FS) | A 14 item questionnaire that screens for feeding difficulties. | Development - Feeding |
Mood and Feelings Questionnaire: Adult Self-Report Long Version (MFQ: Adult Self-Report Long Version) | The Mood and Feelings Questionnaire (MFQ) is a 33-item screening tool that measures depressive symptoms in children and young adults. | Mental Health - Depression/Mood Disorders/Suicide |
Mood and Feelings Questionnaire: Adult Self-Report Short Version (MFQ: Adult Self-Report Short Version) | Screening tool that measures depressive symptoms in adults. The Short Mood and Feelings Questionnaire (SMFQ) is a 13-item subscale from a longer 33-item MFQ questionnaire. | Mental Health - Depression/Mood Disorders/Suicide |
Mood and Feelings Questionnaire: Child Self-Report Long Version | The Mood and Feelings Questionnaire (MFQ) is a 33 item screening tool that measures depressive symptoms in children and young adults. | Mental Health - School Aged Screeners |
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