Child/Teen Questionnaires

Development - Autism Diagnostic

Development - Autism Screening

TM

TM

Development - Feeding

Development - History

Development - Language

  • Infant Development Inventory: Language Domain

  • MacArthur-Bates Communicative Development Inventory (CDI)*

  • MacArthur-Bates CDI: Vocabulary Checklist Level I 

  • MacArthur-Bates CDI: Vocabulary Checklist Level I multiple languages

  • MacArthur-Bates CDI: Vocabulary Checklist Level I in Spanish Only

  • Vocabulary Checklist from the short form CDI:WG, extended with columns for the respondent to indicate whether or not a word with a similar meaning is produced or understood in another language

  • Vocabulary Checklist from the short form CDI:WS, extended with columns for the respondent to indicate whether or not a word with a similar meaning is produced or understood in another language

  • MacArthur-Bates CDI: Words and Gestures* 

  • MacArthur-Bates CDI: Words and Gestures - short form vocabulary with alternative language questions in English*

  • MacArthur-Bates CDI: Words and Gestures*

  • MacArthur-Bates CDI: Words and Gestures Research Version with Percentiles* 

  • MacArthur-Bates CDI: Words and Sentences* 

  • MacArthur-Bates CDI: Words and Sentences French Version*

  • MacArthur-Bates CDI: Words and Sentences (Short Form) II B in Spanish only

  • MacArthur-Bates CDI: Words and Sentences (Short Form) II B multiple languages

Development - Motor

Development - Screening

General Medical - Asthma

General Medical - Bright Futures

General Medical - Clinic Specific Introductory Questionnaires

  • CHOP Introductory Questionnaire

  • Renaissance Pediatrics Introduction
     

General Medical - Data Collection

  • Abilities and Interests 

  • Adjectives to Describe Your Child 

  • Adverse Childhood Experiences and Positive Childhood Experiences (ACE/PCE)

  • Best Parts of Parenting

  • Challenging Parts of Parenting

  • Chief Concern for Visit 

  • Children with Special Health Care Needs Screener© (CSHCN Screener©) 

  • Communication Preferences (JCAHO) and Patient Safety Screen

  • DHCS 7098 A - Staying Healthy Assessment 0-6 Months (SHA 0-6 Months)

  • DHCS 7098 B - Staying Healthy Assessment 7-12 Months (SHA 7-12 Months)

  • DHCS 7098 C - Staying Healthy Assessment 1-2 Years (SHA 1-2 Years)

  • DHCS 7098 D - Staying Healthy Assessment 3-4 Years (SHA 3-4 Years)

  • DHCS 7098 E - Staying Healthy Assessment 5-8 Years (SHA 5-8 Years)

  • DHCS 7098 F - Staying Healthy Assessment 9-11 Years (SHA 9-11 Years)

  • DHCS 7098 G - Staying Healthy Assessment 12-17 Years (Teen Self Report) (SHA 12-17 Years)

  • Goals for Change

  • Initial Patient History

  • Legacy

  • Make a Memory! (Adds notes to your MemoryBook- Optional!)

  • Medication Side Effects (Parent)

  • Medication Side Effects (Teacher)

  • Medication Questionnaire

  • New Patient Questionnaire

  • Ogden Patient Demographics Available in English Experimental

  • Okinawa/Family and Child Strengths and Resources

  • Okinawa/Vision & Hearing Screening

  • One year injury history

  • New PANS Patient Checklist

  • Parent's Concerns

  • Patient Annual Update

  • Positive Childhood Experiences (PCE)

  • Review of Systems 

  • Safety Checklist: 9 Months

  • The ChildHealth Center Well Visit Form 0-5 Months; 6-12 Months; 13-36 Months

  • Visit Introduction

  • Visit Priorities 

  • Visit Priorities and Best and Hardest Parts of Parenting 

  • Visit Priorities, Best and Hardest Parts of Parenting, and Review of Systems

  • Visit Priorities, Best and Hardest Parts of Parenting, ROS, and Chronic Conditions 

  • Visit Priorities, Chronic Conditions, and Best and Hardest Parts of Parenting 

  • Visit Priorities with Chronic Condition

 

General Medical - EPSDT

  • DHCS 7098 A - Staying Healthy Assessment 0-6 Months (SHA 0-6 Months) 

  • DHCS 7098 B - Staying Healthy Assessment 7-12 Months (SHA 7-12 Months)

  • DHCS 7098 C - Staying Healthy Assessment 1-2 Years (SHA 1-2 Years) 

  • DHCS 7098 D - Staying Healthy Assessment 3-4 Years (SHA 3-4 Years) 

  • DHCS 7098 E - Staying Healthy Assessment 5-8 Years (SHA 5-8 Years) 

  • DHCS 7098 F - Staying Healthy Assessment 9-11 Years (SHA 9-11 Years) 

  • DHCS 7098 G - Staying Healthy Assessment 12-17 Years (Teen Self Report) (SHA 12-17 Years) 

  • EPSDT-Anemia Screen 

  • EPSDT - Full Version Maryland

  • EPSDT (Health Risk) 

  • EPSDT (Health Risk): without questions on HIV or chemotherapy (EPSDT) 

  • EPSDT - Heart Risk - Maryland

  • EPSDT-High Cholesterol Screen 

  • EPSDT-High Cholesterol Screen: hereditary risk factors only 

  • EPSDT IVR

  • EPSDT Lead Screening – Arkansas (Arkansas Lead Screening) 

  • EPSDT-TB Screen

  • EPSDT - TX (Health Risk) 

  • EPSDT-VA-Lead Screen 

  • HCY Lead Risk Assessment Guide- Missouri 

  • Illinois Dept. of Public Health: Child lead risk 

  • Lead and Tuberculosis Exposure Screening

  • Lead Exposure Risk Assessment Questionnaire for Children (BCHP)

  • Lead Risk Assessment – Rhode Island 

  • Lead Risk for Tamalpais Pediatrics

  • Lead Screening Questionnaire - TX 

  • Maryland Healthy Kids Preventive Screen - Anemia/STI for Child/Teen Completion 

  • Maryland Healthy Kids Preventive Screen - Lead/TB/CVD for Adult Completion 

  • Pediatric TB Risk Assessment Form - Illinois 

  • Tennessee Tuberculosis Screening Evaluation 

  • Tuberculosis Risk Assessment (BCHP)

  • Tuberculosis Screening Questionnaire - TX
     

General Medical - Family History

General Medical - Healthy Habits/Fitness

  • 24 Hour Food Recall

  • Brenner 'Families in Training' (FIT) 

  • Fit Kid Healthy Habits Questionnaire 

  • Health Habits Questionnaire Ages 10+

  • Obesity Consult General Intake Form

  • Oral Risk Assessment Tool

General Medical - Medical Home Specific

  • Child Medical History 

  • Children with Special Health Care Needs Screener© (CSHCN Screener©)

  • Communication Preferences (JCAHO) and Patient Safety Screen

  • Medical Home Survey

General Medical - Past History

  • Medical Home Survey

  • National Center for Medical Home Implementation

  • Pregnancy and Perinatal History
 
 

General Medical - Sleep

General Medical - Social Determinants of Health

General Medical - Special Health Care Needs

  • Abnormal Involuntary Movement Scale (AIMS 1)

  • Kennedy Krieger Independence Scales - Spina Bifida Version (KKIS-SB)

  • Life Clinic Neuro-Behavioral Questionnaire

  • Transition Readiness Assessment Questionnaire (TRAQ) 

  • World Health Organization Disability Assessment Schedule 2.0 Proxy 12-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Proxy 36-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Self 12-item  (WHODAS)

  • World Health Organization Disability Assessment Schedule 2.0 Self 36-item (WHODAS)

General Medical - Sports

  • Sport Concussion Assessment Tool 2: Symptom Evaluation (SCAT2: Symptom Evaluation) 

  • Sport Concussion Assessment Tool – 3rd ed: Parent symptom evaluation for patients 5 to 12 years old (SCAT3- Parent report)
 

  • Sport Concussion Assessment Tool – 3rd ed: Self-administered background and symptom evaluation for patients 13+ (SCAT3: Self-report) 

  • Sport Concussion Assessment Tool – 3rd ed: Self-administered symptom evaluation for patients 5 to 12 years old (Child-SCAT3- Self-report)

  • Sports Participation Questionnaire (Illinois) 

  • Sports Participation Questionnaire (General) Available in English

  • Sports Physical Clinical Tool

General Medical - Teen/GAPS

  • Adolescent Questionnaire Combined

  • Adolescent Questionnaire Youth

  • BEARS Sleep Screening Tool (Adolescent / Self-report) 

  • Goals Questionnaire

  • Kaiser Teen Questionnaire

  • Kaiser Teen Questionnaire for Parents

  • Transition Readiness Assessment Questionnaire (TRAQ)​

  • Transition Readiness Assessment Questionnaire - 23-item version (TRAQ)

General Medical - Vaccine Information/Consent

  • Influenza Vaccine Consent and Screening Form

  • Influenza Vaccine Consent and Screening Form (Revised without intranasal) (Flu vaccine consent and screening)

  • Screening Checklist for Contraindications to Vaccines for Children and Teens
     

Mental Health - ADHD

TM

Mental Health - Abnormal Movements

Mental Health - Anxiety

Mental Health - Depression/Mood Disorders/Suicide

 

Mental Health - Diagnostic

 

Mental Health - Eating Disorders

  • Eating Attitudes Test (EAT 26)

  • Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS) - Child (NIAS Child)

  • Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS) - Parent

  • SCOFF 
     

Mental Health - Educator/Teacher Administered

 

Mental Health - Family/Environment

 

Mental Health - Infant Screeners

Mental Health - OCD

  • Child Obsessional Compulsive Inventory-Revised Parent Report 10

  • Child Obsessional Compulsive Inventory-Revised Self Report 10

  • Obsessive Compulsive Inventory- Child Version (OCI-CV)

 

Mental Health - Preschool Screeners

 

Mental Health - School Aged Screeners

  • Adaptive Behavior Assessment System Third Edition Parent Form (Ages 5-21) (ABAS-3)*

  • CHADIS DSM 5 Questionnaire (DSM-PC 5 - All modules)

  • Challenging Behaviors for AZ

  • Child Behavior Checklist for Ages 6-18 (CBCL 6-18)* 

  • Child Behavior Checklist for Ages 6-18 French Version (CBCL 6-18)*

  • Children’s Affective Lability Scale (CALS)

  • Conners 3™ - ADHD Index Parent (Conners 3™ - AI-Parent)*

  • Conners 3™ - Global Index Parent (Conners 3™ - GI-Parent)*

  • Conners 3™ - Parent*

  • Conners 3™ - Parent Short*

  • Difficulties in Emotion Regulation Scale (DERS)

  • DSM-PC5 ADHD

  • DSM-PC5 Anxiety

  • DSM-PC 5: Concerns

  • DSM-PC5 Conduct

  • DSM-PC5 Mood

  • Mood and Feelings Questionnaire: Child Self-Report Long Version

  • Mood and Feelings Questionnaire: Child Self-Report Short Version

  • Mood and Feelings Questionnaire: Parent Self-Report Long Version

  • Mood and Feelings Questionnaire: Parent Self-Report Short Version

  • Pediatric Symptom Checklist (PSC-17)

  • Pediatric Symptom Checklist (PSC-35)

  • Problem Behavior Checklist 

  • Strengths and Difficulties Questionnaire© (SDQ) 4-10*

  • Strengths and Difficulties Questionnaire Functional Assessment©*

  • Weiss ADHD Comorbid Health Screen (WACS)*

  • Weiss Functional Impairment Rating Scale – Parent Report (WFIRS-P)*

  • Weiss Functional Impairment Rating Scale – Parent Report averages (WFIRS-P)*

Mental Health - Social Skills

  • Self-Description Inventory 

  • Social Skills Inventory 
     

Mental Health - Substance

 

Mental Health - Teen Administered

 

Mental Health - Teen/Parent Administered

Mental Health - Trauma

  • Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report (Anonymous) CYW (ACE-Q Teen Self-Report (Anonymous) CYW)

  • Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report CYW (ACE-Q Teen Self-Report CYW)

  • Child's Reaction to Traumatic Events Scale (CRTES)

  • Connecticut Trauma Screener - Caregiver Report (CTS - Caregiver Report)

  • Connecticut Trauma Screener - Child Report (CTS - Child Report)

  • PC-PTSD

  • PTSD Checklist for DSM 5 with Life Events Checklist for DSM-5 (PCL-5 with LEC)
 

Clinician Tools

  • Ask Suicide Screening Questions (ASQ) 

  • CRAFFT (Clinician Interview)

  • CRAFFT+N Questionnaire Clinician Version 2.1 (CRAFFT+N Clinician)

  • Clinical Global Impression (CGI)

  • Physical and Neurological Examination for Subtle Signs (PANESS)

  • Sport Concussion Assessment Tool – 3rd ed: Clinician tool for patients 5 to12 years old (Child-SCAT3- Clinician tool for 5-12 years) 

  • Sport Concussion Assessment Tool – 3rd ed: Clinician tool for patients 13 years and older (SCAT3: Clinician tool 13+ years ) 

  • Sports Physical Clinical Tool 

  • Theory of Mind
     

Consent

  • Consent to Treat Minor Children

  • Exchange of Information Consent for ADHD Care 

  • Optimizing Collaborative Care of Mississippi Children - Parent Consent 

  • Pre Camp Form

  • SBIRT Consent Form

 

Quality Monitoring/Satisfaction

  • CHADIS Feedback Questionnaire: Parent Version 

  • Cleveland Clinic Parent Satisfaction Questions 

  • Hampton Pediatrics Patient Satisfaction Survey

  • Parent's View of Child's Health Care

  • Pro-PHDS 3-9 Months 

  • Pro-PHDS 10-18 Months 

  • Pro-PHDS 19-48 Months 

  • Service Provider Questionnaire

  • Session Alliance Inventory (Patient Version)

  • Treatment Acceptability Rating Form (TAR-F)

  • Working Alliance Inventory - Short Revised (WAI-SR) Available in English Experimental

* These questionnaires may have an additional cost associated with them. Ask your account manager or sales representative for details.