"*" 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/him 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 detained, arrested or incarceratedYour child was often treated badly because of race, sexual orientation, place of birth, disability or religionYour child 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 TotalYou’re doing great. Click or tap "Next" to continue to the next section. You’re doing great. Click or tap “Next” to continue to the next section. Directions: Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.Name First Last HiddenDate MM slash DD slash YYYY If 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 911.1. When my child feels frightened , it is hard for him/her to breathe* Not at all Several Days More than half the days2. My child gets headaches when he/she is at school* Not at all Several Days More than half the days3. My child doesn't like to be with people he/she doesn't know well* Not at all Several Days More than half the days4. My child gets scared if he/she sleeps away from home* Not at all Several Days More than half the days5. My child worries about other people liking him/her* Not at all Several Days More than half the days6. When my child gets frightened , he/she feels like passing out* Not at all Several Days More than half the days7. My child is nervous* Not at all Several Days More than half the days8. My child follows me wherever I go* Not at all Several Days More than half the days9. People tell me that my child looks nervous* Not at all Several Days More than half the days10. My child feels nervous with people he/she doesn't know well* Not at all Several Days More than half the days11. My child gets stomachaches at school* Not at all Several Days More than half the days12. When my child gets frightened , he/she feels like he/she is going crazy* Not at all Several Days More than half the days13. My child worries about sleeping alone* Not at all Several Days More than half the days14. My child worries about being as good as other kids* Not at all Several Days More than half the days15. When he/she gets frightened , he/she feels like things are not real* Not at all Several Days More than half the days16. My child has nightmares about something bad happening to his/her parents* Not at all Several Days More than half the days17. My child worries about going to school* Not at all Several Days More than half the days18. When my child gets frightened, his/her heart beats fast* Not at all Several Days More than half the days19. He/she gets shaky* Not at all Several Days More than half the days20. My child has nightmares about something bad happening to him/her* Not at all Several Days More than half the days21. My child worries about things working out for him/her* Not at all Several Days More than half the days22. When my child gets frightened, he/she sweats a lot* Not at all Several Days More than half the days23. My child is a worrier* Not at all Several Days More than half the days24. My child gets really frightened for no reason at all* Not at all Several Days More than half the days25. My child is afraid to be alone in the house* Not at all Several Days More than half the days26. It is hard for my child to talk with people he/she doesn't know well* Not at all Several Days More than half the days27. When my child gets frightened, he/she feels like he/she is choking* Not at all Several Days More than half the days28. People tell me that my child worries too much* Not at all Several Days More than half the days29. My child doesn't like to be away from his/her family* Not at all Several Days More than half the days30. My child is afraid of having anxiety (or panic) attacks* Not at all Several Days More than half the days31. My child worries that something bad might happen to his/her parents* Not at all Several Days More than half the days32. My child feels shy with people he/she doesn't know well* Not at all Several Days More than half the days33. My child worries about what is going to happen in the future* Not at all Several Days More than half the days34. When my child gets frightened, he/she feels like throwing up* Not at all Several Days More than half the days35. My child worries about how well he/she does things* Not at all Several Days More than half the days36. My child is scared to go to school* Not at all Several Days More than half the days37. My child worries about things that have already happened* Not at all Several Days More than half the days38. When my child gets frightened, he/she feels dizzy* Not at all Several Days More than half the days39. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport)* Not at all Several Days More than half the days40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn't know well* Not at all Several Days More than half the days41. My child is shy* Not at all Several Days More than half the daysHiddenAnxiety Disorder (Total) - ParentHiddenPanic Disorder or Significant Somatic Symptoms Score - ParentHiddenGeneralized Anxiety Disorder - ParentHiddenSeparation Anxiety Disorder - ParentHiddenSocial Anxiety Disorder - ParentHiddenSchool Avoidance - ParentThank 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. 96024
