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