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2020 - Covid Policy Addendum 2020- Established PT Update 2020- Health History 2020- New Patient Intake 2020- Office Policy/CCOF ACT--Asthma control Test (12yr+) ACT--Asthma control Test (4-11yr) ADHD Parent Follow Up ADHD Parent Initial Behavioral intake (for ages 8 and older) Behavioral intake (up to 7 years old) Complete Packet- 0-5 day (newborn) Complete Packet- 1 month Complete Packet- 10 year Complete packet- 11-14 yr (parent) Complete Packet- 12 months Complete Packet- 15 months Complete packet- 15-17year (parent) Complete Packet- 18 months Complete Packet- 2 month Complete Packet- 24 months Complete Packet- 3 year Complete Packet- 4 month Complete Packet- 4 Year Complete Packet- 5 yr Complete Packet- 6 Months Complete Packet- 6 yr Complete Packet- 7 yr Complete Packet- 8 Year Complete Packet- 8 Year Complete Packet- 9 Months Complete Packet- 9 year Complete Packet- Older Adolescent Packet 15-18 (child) Complete Packet- Younger Adolescent 11-14 (Child) Complete Packet-30 month Covid consent COVID Test- Non Patient Covid Vaccine Registration GAPS 11-14yr GAPS 15-18yr Generalized Anxiety Disorder 7-Item Scale PHQ9 Prevaccination Checklist for COVID-19 Vaccines RAPID TEST ONLY- Patient Intake Release of records TO IDEAL PEDIATRICS SCARED Vaccine Declination Vaccine FLU Contraindications Vaccine Screening for Contraindication Vaccine VFC Eligibility Screening

SCARED

Screen for Child Anxiety Related Disorders (SCARED) CHILD Version (to be filled out by the CHILD)

Name:

Date:

Directions: Below is a list of sentences that describe how people feel. Reach 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, fill in one circle that corresponds to the response that seems to describe you for the last 3 months.

1. When I feel frightened, it is hard to breathe

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

2. I get headaches when I am at school

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SH

3. I don't like to be with people I don't know well

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

4. I get scared if I sleep away from home

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

5. I worry about other people like me

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

6. When I get frightened, I feel like passing out

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

7. I am nervous

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

8. I follow my mother or father wherever they go

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

9. People tell me that I look nervous

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

10. I feel nervous with people I don't know well

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

11. I get stomachaches at school

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SH

12. When I get frightened, I feel like I am going crazy

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

13. I worry about sleeping alone

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

14. I worry about being as good as other kids

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

15. When I get frightened, I feel like things are not real

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

16. I have nightmares about something bad happening to my parents

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

17. I worry about going to school

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SH

18. When I get frightened, my heart beats fast

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

19. I get shaky

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

20. I have nightmares about something bad happening to me

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

21. I worry about things working out for me

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

22. When I get frightened, I sweat a lot

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

23. I am a worrier

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

24. I get really frightened for no reason at all

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

25. I am afraid to be alone in the house

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

26. It is hard for me to talk with people I don't know well

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

27. When I get frightened, I feel like I'm choking

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

28. People tell me that I worry too much

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

29. I don't like to be away from my family

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

30. I am afraid of having anxiety (or panic) attacks

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

31. I worry that something bad might happen to my parents

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SP

32. I feel shy with people I don't know well

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

33. I worry about what is going to happen in the future

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

34. When I get frightened, I feel like throwing up

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

35. I worry about how well I do things

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

36. I am scared to go to school

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SH

37. I worry about things that have already happened

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

GD

38. When I get frightened, I feel dizzy

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

PN

39. 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 True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

40. 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 True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

41. I am shy

Not True or Hardly Ever True

Somewhat True or Sometimes True

Very True or Often True

SC

SCORING

A total score of less than or equal to 25 may indicate the presence of an Anxiety Disorder. Scores higher than 30 are more specific. Total:

A score of 7 for items 1, 6, 9, 12, 15, 18, 19, 22, 24, 27, 30, 34, 38 may indicate Panic Disorder or Significant Somatic Symptoms. PN =

A score of 9 for items 5, 7, 14, 21, 23, 28, 33, 35, 37 may indicate Generalized Anxiety Disorder GD =

A score of 5 for items 4, 8, 13, 16, 20, 25, 29, 31 may indicate Separation Anxiety Disorder SP =

A score of 8 for items 3, 10, 26, 32, 39, 40, 41 may indicate Social Anxiety Disorder SC =

A score of 3 for items 2, 11, 17, 36 may indicate Significant School Avoidance SH =

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