"*" indicates required fields HiddenAssessment Date* MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Race/Ethnicity*Please Choose...American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino or Spanish OriginNative Hawaiian or Other Pacific IslanderWhitePrefer not to answerZIP Code*How many statements below apply to you?At any point since you were born...Your parents or guardians were separated or divorcedYou lived with someone who had a problem with drinking or using drugsYou lived with a household member who served time in jail or prisonSomeone pushed, grabbed, slapped or threw something at you OR you were hit so hard that you were injured or had marksA household member swore at, insulted, humiliated, or put you down in a way that scared you OR a household member acted in a way that made you afraid that you might be physically hurtTotal*Please enter a number from 0 to 5.How many statements below apply to you?At any point since you were born...You often felt unsupported, unloved and/or unprotectedMore than once, you went without food, clothing, a place to live, or had no one to protect youYou saw or heard household members hurt or threaten to hurt each otherSomeone touched your private parts or asked you to touch their private parts in a sexual wayYou lived with a household member who was depressed, mentally ill or attempted suicideTotal*Please enter a number from 0 to 5.How many statements below apply to you?At any point since you were born...You have been in foster careYou have experienced harassment or bullying at schoolYou have lived with a parent or guardian who diedYou have been separated from your primary caregiver through deportation or immigrationYou have had a serious medical procedure or life threatening illnessYou have often seen or heard violence in the neighborhood or in your school neighborhoodYou have been detained, arrested or incarceratedYou have often been treated badly because of race, sexual orientation, place of birth, disability or religionYou have experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)Total*Please enter a number from 0 to 9.HiddenACE-Q TotalsYou’re doing great. Click or tap "Next" to continue to the next section. You’re doing great. Please have the patient take this tablet into your appointment to finish with your health care provider.Patients Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male FemalePeople sometimes experience a traumatic or negative event. Traumatic or negative events might include being threatened or hurt, seeing someone else threatened or hurt, or feeling like your life was in danger.Have you ever experienced a traumatic or negative event?* Yes NoWhat was the traumatic or negative event? Please select any that apply. Psychological abuse Physical abuse Sexual abuse Violence or assault Witnessing or experiencing domestic violence Sudden or violent loss of a loved one Military deployment or loss Neglect Accidents or life-threatening illness OtherIf other, please specify.When thinking about the traumatic or negative events, how often have the following problems happened to you during the past 30 days?Had upsetting thoughts, images, or memories of the event come into your mind when you didn’t want them to?* Never Sometimes OftenFelt afraid, scared, or sad when something reminded you about the event?* Never Sometimes OftenTried to stay away from people, places, or activities that reminded you of the event?* Never Sometimes OftenHad trouble feeling happiness, enjoyment, or love?* Never Sometimes OftenBeen on the lookout for danger or other things that you are afraid of (for example, looking over your shoulder when nothing is there)?* Never Sometimes OftenHiddenTSSCA ScoreYou’re doing great. Click or tap “Next” to continue to the next section. PHQ-9 modified for Adolescents (PHQ-A)Name First Last ClinicianDate MM slash DD slash YYYY Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom select the box beneath the answer that best describes how you have been feeling.1. Feeling down, depressed, irritable, or hopeless?* Not at all Several Days More than half the days Nearly every day2. Little interest or pleasure in doing things?* Not at all Several Days More than half the days Nearly every day3. Trouble falling asleep, staying asleep, or sleeping too much?* Not at all Several Days More than half the days Nearly every day4. Poor appetite, weight loss, or overeating?* Not at all Several Days More than half the days Nearly every day5. Feeling tired, or having little energy?* Not at all Several Days More than half the days Nearly every day6. Feeling bad about yourself – or feeling that you are a failure, or that you have let yourself or your family down?* Not at all Several Days More than half the days Nearly every day7. Trouble concentrating on things like school work, reading, or watching TV?* Not at all Several Days More than half the days Nearly every day8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?* Not at all Several Days More than half the days Nearly every day9. Thoughts that you would be better off dead, or of hurting yourself in some way?* Not at all Several Days More than half the days Nearly every dayIn the PAST YEAR have you felt depressed or sad most days, even if you felt okay sometimes?* Yes NoIf you are experiencing any of the problems on this form, how DIFFICULT have these problems made it for you to do your work, take care of things at home or get along with other people?* Not difficult at all Somewhat difficult Very difficult Extremely difficultHas there been a time in the LAST 30 DAYS when you have had serious thoughts about ending your life?* Yes NoHave you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?* Yes NoIf you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.HiddenPHQ ScoreGAD-7Over the last 2 weeks, how often have you been bothered by the following problems?1. Feeling nervous, anxious or on edge* Not at all Several Days More than half the days Nearly every day2. Not being able to stop or control worrying* Not at all Several Days More than half the days Nearly every day3. Worrying too much about different things* Not at all Several Days More than half the days Nearly every day4. Trouble relaxing* Not at all Several Days More than half the days Nearly every day5. Being so restless that it is hard to sit still* Not at all Several Days More than half the days Nearly every day6. Becoming easily annoyed or irritable* Not at all Several Days More than half the days Nearly every day7. Feeling afraid as if something awful might happen* Not at all Several Days More than half the days Nearly every dayHiddenTotal Score - GAD-7Thank you!You have completed the screening. Please click the “Finish” button below to return to the home page. If you are completing this in the clinic, please return the tablet to your health care provider. 21334