"*" indicates required fieldsHiddenAssessment Date* MM slash DD slash YYYY Patient's Name* First Last Date of Birth* MM slash DD slash YYYY Patient's Race/Ethnicity*Please Choose...American Indian or Alaska NativeAsianBlack or African AmericanHispanic or Latino or Spanish OriginNative Hawaiian or Other Pacific IslanderWhitePrefer not to answerYour Name* First Last Relationship to Child*Please Choose...MotherFatherGrandmotherGrandfatherSiblingAuntUncleCousinNeighborFoster ParentOtherZIP Code*Section 1How many statements below apply to your child?At any point since your child was born...Your child’s parents or guardians were separated or divorcedYour child lived with someone who had a problem with drinking or using drugsYour child lived with a household member who served time in jail or prisonSomeone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marksA household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurtTotal*Please enter a number from 0 to 5.Section 2How many statements below apply to your child? At any point since your child was born...Your child often felt unsupported, unloved and/or unprotectedMore than once, your child went without food, clothing, a place to live, or had no one to protect her/himYour child saw or heard household members hurt or threaten to hurt each otherSomeone touched your child’s private parts or asked your child to touch their private parts in a sexual wayYour child lived with a household member who was depressed, mentally ill or attempted suicideTotal*Please enter a number from 0 to 5.Section 3How many statements below apply to your child? At any point since your child was born...Your child was in foster careYour child experienced harassment or bullying at schoolYour child lived with a parent or guardian who diedYour child was separated from her/his primary caregiver through deportation or immigrationYour child had a serious medical procedure or life threatening illnessYour child often saw or heard violence in the neighborhood or in her/his school neighborhoodYour child was often treated badly because of race, sexual orientation, place of birth, disability or religionTotal*Please enter a number from 0 to 7.HiddenACE-Q ScoreYou’re doing great. Click or tap "Next" to continue to the next section.Directions:Below is a list of items that describe children. For each item please choose the response that best describes your child. Please choose the 4 if the item is very often true, 3 if the item is quite often true, 2 if the item is sometimes true, 1 if the item is seldom true or if it is not true at all choose 0. Please answer all the items as well as you can, even if some do not seem to apply to your child.Your Name First Last Date MM slash DD slash YYYY Your Child's Name First Last 1. Has difficulty stopping him/herself from worrying* Not True at All Seldom True Sometimes True Quite Often True Very Often True2. Worries that he/she will do something to look stupid in front of other people* Not True at All Seldom True Sometimes True Quite Often True Very Often True3. Keeps checking that /he/she has done things right (e.g., that he/she closed a door, turned off a tap)* Not True at All Seldom True Sometimes True Quite Often True Very Often True4. Is tense, restless or irritable due to worrying* Not True at All Seldom True Sometimes True Quite Often True Very Often True5. Is scared to ask an adult for help (e.g. a preschool or school teacher)* Not True at All Seldom True Sometimes True Quite Often True Very Often True6. Is reluctant to go to sleep without you or to sleep away from home* Not True at All Seldom True Sometimes True Quite Often True Very Often True7. Is scared of heights (high places)* Not True at All Seldom True Sometimes True Quite Often True Very Often True8. Has trouble sleeping due to worrying* Not True at All Seldom True Sometimes True Quite Often True Very Often True9. Washes his/her hands over and over many times each day* Not True at All Seldom True Sometimes True Quite Often True Very Often True10. Is afraid of crowded or closed-in places* Not True at All Seldom True Sometimes True Quite Often True Very Often True11. Is afraid of meeting or talking to unfamiliar people* Not True at All Seldom True Sometimes True Quite Often True Very Often True12. Worries that something bad will happen to his/her parents* Not True at All Seldom True Sometimes True Quite Often True Very Often True13. Is scared of thunder storms* Not True at All Seldom True Sometimes True Quite Often True Very Often True14. Spends a large part of each warring about various things* Not True at All Seldom True Sometimes True Quite Often True Very Often True15. Is afraid of talking in front of the class (preschool group) e.g., show and tell* Not True at All Seldom True Sometimes True Quite Often True Very Often True16. Worries that something bad might happen to him/her (e.g., getting lost or kidnapped), so he/she won't be able to see you again* Not True at All Seldom True Sometimes True Quite Often True Very Often True17. Is nervous of going swimming* Not True at All Seldom True Sometimes True Quite Often True Very Often True18. Has to have things in exactly the right order or position to stop bad things from happening* Not True at All Seldom True Sometimes True Quite Often True Very Often True19. Worries that he/she will do something embarrassing in front of other people* Not True at All Seldom True Sometimes True Quite Often True Very Often True20. Is afraid of insects and/or spiders* Not True at All Seldom True Sometimes True Quite Often True Very Often True21. Has bad or silly thoughts or images that keep coming back over and over* Not True at All Seldom True Sometimes True Quite Often True Very Often True22. Becomes distressed about your leaving him/her at preschool/school or with a babysitter* Not True at All Seldom True Sometimes True Quite Often True Very Often True23. Is afraid to go up to a group of children and join their activities* Not True at All Seldom True Sometimes True Quite Often True Very Often True24. Is frightened of dogs* Not True at All Seldom True Sometimes True Quite Often True Very Often True25. Has nightmares about being apart from you* Not True at All Seldom True Sometimes True Quite Often True Very Often True26. Is afraid of the dark* Not True at All Seldom True Sometimes True Quite Often True Very Often True27. Has to keep thinking special thoughts (e.g., numbers or words) to stop bad things from happening* Not True at All Seldom True Sometimes True Quite Often True Very Often True28. Asks for reassurance when it doesn't seem necessary* Not True at All Seldom True Sometimes True Quite Often True Very Often True29. Has your child ever experienced anything really bad or traumatic (e.g., severe accident, death of a family member/friend, assault, robbery, disaster)* Yes NoPlease briefly describe the event that your child experienced*Do the following statements describe your child's behavior since the event?30. Has bad dreams or nightmares about the event* Not True at All Seldom True Sometimes True Quite Often True Very Often True31. Remembers the event and becomes distressed* Not True at All Seldom True Sometimes True Quite Often True Very Often True32. Becomes distressed when reminded of the event* Not True at All Seldom True Sometimes True Quite Often True Very Often True33. Suddenly behaves as if he/she is reliving the bad experience* Not True at All Seldom True Sometimes True Quite Often True Very Often True34. Shows bodily signs of fear (e.g., sweating, shaking or racing heart) when reminded of the event* Not True at All Seldom True Sometimes True Quite Often True Very Often TrueHiddenSeparation anxietyHiddenSocial anxietyHiddenObsessive-compulsive disorderHiddenPersonal injury fearsHiddenGeneralized anxietyHiddenAnxiety Scale Score Total Thank you for taking this screening. Please take this tablet into your appointment to finish with your child's health care provider.Patient Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female People 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 OtherOther, 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 Score Thank 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 child's health care provider. 41316