"*" indicates required fields HiddenAssessment 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. Thank you for taking this screening. Please take this tablet into your appointment to finish with your health care provider. 64647