11-17 SCREENERS (CHILD DOES) ACES – TEEN SELF GAD-11-17 GAIN-SS PHQ-A Step 1 of 5 20% ACEs TEEN (11-17) Self-ReportDate MM slash DD slash YYYY Name(Required) First Last Email(Required) Pediatrics ACEs and Related Life Events Screener (PEARLS)TEEN (Self-Report)- To be completed by: Patient. At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences. Please note, some questions have more than one part separated by “OR.” If any part of the question is answered “Yes,” then the answer to the entire question is “Yes.”If you are having a difficult time with answering any of these questions, check the YES below and skip to the next page. Thank you. Yes 1. Have you ever lived with a parent/caregiver who went to jail/prison? Yes No 2. Have you ever felt unsupported, unloved and/or unprotected? Yes No 3. Have you ever lived with a parent/caregiver who had mental health issues? (for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder) Yes No 4. Has a parent/caregiver ever insulted, humiliated, or put you down? Yes No 5. Has your biological parent or any caregiver ever had, or currently has a problem with too much alcohol, street drugs or prescription medications use? Yes No 6. Have you ever lacked appropriate care by any caregiver? (for example, not being protected from unsafe situations, or not being cared for when sick or injured even when the resources were available) Yes No 7. Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted, or humiliated by another adult? OR have you ever seen or heard a parent/caregiver being slapped, kicked, punched, beaten up, or hurt with a weapon? Yes No 8. Has any adult in the household often or very often pushed, grabbed, slapped, or thrown something at you? OR has any adult in the household ever hit you so hard that you had marks or were injured? OR has any adult in the household ever threatened you or acted in a way that made you afraid that you might be hurt? Yes No 9. Have you ever experienced sexual abuse? (for example, has anyone touched you or asked you to touch that person in a way that was unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with you) Yes No 10. Have there ever been significant changes in the relationship status of your caregiver(s)? (for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out) Yes No 11. Have you ever seen, heard, or been a victim of violence in your neighborhood, community or school? (for example, targeted bullying, assault or other violent actions, war or terrorism) Yes No 12. Have you experienced discrimination? (for example, being hassled or made to feel inferior or excluded because of their race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities) Yes No 13. Have you ever had problems with housing? (for example, being homeless, not having a stable place to live, moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members) Yes No 14. Have you ever worried that you did not have enough food to eat or that food would run out before you or your parent/caregiver could buy more? Yes No 15. Have you ever been separated from your parent or caregiver due to foster care, or immigration? Yes No 16. Have you ever lived with a parent/caregiver who had a serious physical illness or disability? Yes No 17. Have you ever lived with a parent or caregiver who died? Yes No 18. Have you ever been detained, arrested or incarcerated? Yes No 19. Have you ever experienced verbal or physical abuse or threats from a romantic partner? (for example, a boyfriend or girlfriend) Yes No Name(Required) First Last Generalized Anxiety Disorder 7-Item (GAD-11-17) FormOver the last 2 weeks, how often have you been bothered by the following problems?felt moments of sudden terror, fear, or fright(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 felt anxious, worried or nervous(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 had thoughts of bad things happening, such as family tragedy, ill health, loss of job, or accidents(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 felt a racing heart, sweaty, trouble breathing, faint or shaky(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 avoided, or did not approach or enter, situations about which I worry(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 left situations early or participated only minimally due to worries(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 sought reassurance from others due to worries(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 needed help to cope with anxiety (e.g., alcohol or medication, superstitious objects, or other people)(Required) Never – 0 Occasionally- 1 Half of the time – 2 Most of the time- 3 All of the time – 4 Name(Required) First Last GAIN-SS (11-17)The following questions are about common psychological, behavioral and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on.IDSscrAfter each of the following questions. Please tell us the last time you had this problem, if ever, by answering (circling) whether it was in the past month (4); 2-3 months ago (3); 4-12 months ago (2); 1 or more years ago (1); or never (0). Be sure to choose only one response. Please tell us when the last time you had significant problems.Felt trapped, lonely, sad, blue, depressed or hopeless about the future(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Had sleep trouble, such as bad dreams, sleeping restlessly or falling asleep during the day(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Felt very anxious, nervous, tense, scared, panicked or like something bad was going to happen(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Became very distressed and upset when something reminded you of the past(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Thought about ending your life or committing suicide(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Saw or heard things that no one else could see or hear or felt that someone else could read or control your thoughts(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 EDSscrWhen was the last time you did the following things two or more times?Lied or conned to get things you wanted or to avoid having to do something(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Had a hard time paying attention at school, work, or home(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Had a hard time listening to instruction at school, work, or home(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Had a hard time waiting your turn(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Were a bully or threatened other people(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Started a physical fight with other people(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Tried to win back your gambling losses by going back another day(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 SDSscrWhen was the last time that…Used alcohol or other drugs weekly or more often….(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 You had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 CVSscrWhen was the last time that…Had a disagreement in which you pushed, grabbed, or shoved someone(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Took something from a store without paying for it(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Sold, distributed, or helped to make illegal drugs(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Drove a vehicle while under the influence of alcohol or illegal drugs(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Purposely damaged or destroyed property that did not belong to you(Required) Past Month – 4 2-3 Months – 3 4-12 Months – 2 1+ year – 1 Never – 0 Do you have other significant psychological, behavioral or personal problems that you want treatment for or help with? If yes, please describe: Name(Required) First Last PHQ-A (11-17)Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check the box next to the number that best describes how often you have been bothered by these problems. Feeling down, depressed, or hopeless?(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Little interest or pleasure in doing things:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Trouble falling or staying asleep, or sleeping too much:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Poor appetite, weightloss, or overeating:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Feeling tired or having little energy:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Feeling bad about yourself — or that you are a failure or have let yourself or your family down:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Trouble concentrating on things, such as school work, reading or watching TV.(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 Thoughts that you would be better off dead or of hurting yourself in some way:(Required) Not at all – 0 Several days – 1 More than half the days – 2 Nearly everyday – 3 SDQ-S (11-17)Name(Required) First Last I am considerate of other people's feelings(Required) Not true Somewhat true Certainly true I am restless, I cannot stay still for long(Required) Not true Somewhat true Certainly true I get a lot of headaches, stomach-aches or sickness(Required) Not true Somewhat true Certainly true I usually share with others, for example CD's, games, food(Required) Not true Somewhat true Certainly true I get very angry and often lose my temper(Required) Not true Somewhat true Certainly true I would rather be alone than with people my age(Required) Not true Somewhat true Certainly true I usually do as I am told(Required) Not true Somewhat true Certainly true I worry a lot(Required) Not true Somewhat true Certainly true I am helpful if someone is hurt, upset or feeling ill(Required) Not true Somewhat true Certainly true I am constantly fidgeting or squirming(Required) Not true Somewhat true Certainly true I have one good friend or more(Required) Not true Somewhat true Certainly true I fight a lot. I can make other people do what I want.(Required) Not true Somewhat true Certainly true I am often unhappy, depressed or tearful(Required) Not true Somewhat true Certainly true Other people my age generally like me(Required) Not true Somewhat true Certainly true I am easily distracted, I find it difficult to concentrate(Required) Not true Somewhat true Certainly true I am nervous in new situations. I easily lose confidence.(Required) Not true Somewhat true Certainly true I am kind to younger children.(Required) Not true Somewhat true Certainly true I am often accused of lying or cheating.(Required) Not true Somewhat true Certainly true Other children or young people pick on me or bully me(Required) Not true Somewhat true Certainly true I often offer to help others (parents, teachers,children)(Required) Not true Somewhat true Certainly true I think before I do things(Required) Not true Somewhat true Certainly true I take things that are not mine from home, school or elsewhere(Required) Not true Somewhat true Certainly true I get along better with adults than with people my own age(Required) Not true Somewhat true Certainly true I have many fears, I am easily scared(Required) Not true Somewhat true Certainly true I finish the work I am doing. My attention is good.(Required) Not true Somewhat true Certainly true The above information is true to the best of my knowledge(Required) By clicking this, I am acknowledging this to be true to the best of my knowledge.
