Guidelines for Adolescent Prevenative Services
THIS FORM SHOULD BE COMPLETED BY THE CHILD
Specific Health Issues
select all that apply
These questions will help us get to know you better. Choose the answer that best describes what you feel or do. Your answers will be seen only by your health care provider and his/her assistant.
Friends & Family
Screen for Child Anxiety Related Disorders
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.
Over the last 2 weeks how often have you been bothered by any of the following problems? (please check the box that applies)