"*" indicates required fields HiddenAssessment Date* MM slash DD slash YYYY 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 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 7.HiddenACE-Q Total You’re doing great. Click or tap "Next" to continue to the next section. Thank you for completing the screening. Please have your child take this tablet into the appointment to finish with the 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 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. Screen for Child Anxiety Related Disorders (SCARED)Child Version To be filled out by the CHILDName First Last HiddenDate MM slash DD slash YYYY Directions:Below is a list of sentences that describe how people feel. Read each phrase and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for you. Then for each sentence, make the selection that corresponds to the response that seems to describe you FOR THE LAST 3 MONTHS.*For children ages 8 to 11, it is recommended that the clinician explain all questions, or have the child answer the questionnaire sitting with an adult in case they have any questions.1. When I feel frightened, it is hard for me to breathe* Not at all Several Days More than half the days2. I get headaches when I am at school* Not at all Several Days More than half the days3. I don't like to be with people I don't know well* Not at all Several Days More than half the days4. I get scared if I sleep away from home* Not at all Several Days More than half the days5. I worry about other people liking me* Not at all Several Days More than half the days6. When I get frightened, I feel like passing out* Not at all Several Days More than half the days7. I am nervous* Not at all Several Days More than half the days8. I follow my mother or father wherever they go* Not at all Several Days More than half the days9. People tell me that I look nervous* Not at all Several Days More than half the days10. I feel nervous with people I don't know well* Not at all Several Days More than half the days11. My I get stomachaches at school* Not at all Several Days More than half the days12. When I get frightened, I feel like I am going crazy* Not at all Several Days More than half the days13. I worry about sleeping alone* Not at all Several Days More than half the days14. I worry about being as good as other kids* Not at all Several Days More than half the days15. When I get frightened, I feel like things are not real* Not at all Several Days More than half the days16. I have nightmares about something bad happening to my parents* Not at all Several Days More than half the days17. I worry about going to school* Not at all Several Days More than half the days18. When I get frightened, my heart beats fast* Not at all Several Days More than half the days19. I get shaky* Not at all Several Days More than half the days20. I have nightmares about something bad happening to me* Not at all Several Days More than half the days21. I worry about things working out for me* Not at all Several Days More than half the days22. When I get frightened , I sweat a lot* Not at all Several Days More than half the days23. I am a worrier* Not at all Several Days More than half the days24. I get really frightened for no reason at all* Not at all Several Days More than half the days25. I am afraid to be alone in the house* Not at all Several Days More than half the days26. It is hard for me to talk with people I don't know well* Not at all Several Days More than half the days27. When I get frightened, I feel like I am choking* Not at all Several Days More than half the days28. People tell me that I worry too much* Not at all Several Days More than half the days29. I don't like to be away from my family* Not at all Several Days More than half the days30. I am afraid of having anxiety (or panic) attacks* Not at all Several Days More than half the days31. I worry that something bad might happen to my parents* Not at all Several Days More than half the days32. I feel shy with people I don't know well* Not at all Several Days More than half the days33. I worry about what is going to happen in the future* Not at all Several Days More than half the days34. When I get frightened, I feel like throwing up* Not at all Several Days More than half the days35. I worry about how well I do things* Not at all Several Days More than half the days36. I am scared to go to school* Not at all Several Days More than half the days37. I worry about things that have already happened* Not at all Several Days More than half the days38. When I get frightened, I feel dizzy* Not at all Several Days More than half the days39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport)* Not at all Several Days More than half the days40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well* Not at all Several Days More than half the days41. I am shy* Not at all Several Days More than half the daysHiddenAnxiety Disorder (Total) - ChildHiddenPanic Disorder or Significant Somatic Symptoms Score - ChildHiddenGeneralized Anxiety Disorder - ChildHiddenSeparation Anxiety Disorder - ChildHiddenSocial Anxiety Disorder - ChildHiddenSchool Avoidance - ChildThank 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 the health care provider. 20766