Priority Pediatrics PC

Available Forms

1. NEW Patient Online Intake History Form for Dr. T 2. ESTABLISHED Patient Online Interim History Form for Dr. T 3. Lead Exposure Risk Questionnaire for parent to complete for Dr. T 4. Request to Transfer Medical Records to Priority Pediatrics 5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T 6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T 7. Adolescent Mood Questionnaire for the Teen to complete for Dr. T 8 Side Effect Patient Check List 9. Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T 10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T

A Confidential Youth Survey (ages 11-18 years) from Dr. T

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Your answers that you share with Dr. T will be kept confidential and will be part of your medical record. You can talk with Dr. T about any of these questions and your answers in person or by phone or text.

Name of Youth &/or person completing checklist on Youth's behalf *

The Youth's answers, please!

Date of Completion *

Please indicate under the heading that best describes how you feel: Never/No, Sometimes, Often.

1. Complain of aches or pains *

Never (0)

Sometimes (1)

Often (2)

2. Spend more time alone *

No (0)

Sometimes (1)

Often (3)

3. Tire easily; have little energy *

No (0)

Sometimes (1)

Often (3)

4. Very fidgety; unable to sit still *

No (0)

Sometimes (1)

Often (3)

5. Have trouble with teacher *

No (0)

Sometimes (1)

Often (3)

6. Less interested in school *

No (0)

Sometimes (1)

Often (3)

7. Act as if driven by a motor; lots of energy to get things done. *

No (0)

Sometimes (1)

Often (3)

8. Daydream too much; gets in the way of getting things done *

No (0)

Sometimes (1)

Often (3)

9. Distract easily; interferes with getting things done *

No (0)

Sometimes (1)

Often (3)

10. Am afraid of new situations *

No (0)

Sometimes (1)

Often (3)

11. Feel sad, unhappy *

No (0)

Sometimes (1)

Often (3)

12. Am irritable, angry *

No (0)

Sometimes (1)

Often (3)

13. Feel hopeless *

No (0)

Sometimes (1)

Often (3)

14. Have trouble concentrating *

No (0)

Sometimes (1)

Often (3)

15. Less interested in friends than I used to be *

No (0)

Sometimes (1)

Often (3)

16. Fight with other children *

No (0)

Sometimes (1)

Often (3)

17. Absent from School *

No (0)

Sometimes (1)

Often (3)

18. School grades are dropping *

No (0)

Sometimes (1)

Often (3)

19. Down on myself *

No (0)

Sometimes (1)

Often (3)

20. My doctor(s) find nothing wrong when I am seen *

No (0)

Sometimes (1)

Often (3)

21. Have trouble sleeping *

No (0)

Sometimes (1)

Often (3)

This can be either going to sleep or remaining asleep through the night.

22. Worry a lot *

No (0)

Sometimes (1)

Often (3)

23. Want to be with parent(s) more than before *

No (0)

Sometimes (1)

Often (3)

24. Feel bad *

No (0)

Sometimes (1)

Often (3)

25. Take unnecessary risks *

No (0)

Sometimes (1)

Often (3)

26. Get hurt frequently *

No (0)

Sometimes (1)

Often (3)

27. Seem to be having less fun *

No (0)

Sometimes (1)

Often (3)

28. Act younger than others my age *

No (0)

Sometimes (1)

Often (3)

29. Do not listen to rules *

No (0)

Sometimes (1)

Often (3)

Includes getting into trouble for breaking rules.

30. Do not show my feelings *

No (0)

Sometimes (1)

Often (3)

I keep my feelings to myself.

31. Do not understand other people's feelings *

No (0)

Sometimes (1)

Often (3)

32. Tease others *

No (0)

Sometimes (1)

Often (3)

33. Blame others for my troubles *

No (0)

Sometimes (1)

Often (3)

34. Take things that do not belong to me *

No (0)

Sometimes (1)

Often (3)

35. Refuse to share with others *

No (0)

Sometimes (1)

Often (3)

36. During the past three months, have had thoughts of hurting or killing myself *

No (0)

Sometimes (1)

Often (3)

37. Have ever tried to hurt or kill myself *

No (0)

Sometimes (1)

Often (3)

This includes self-injury, like cutting self.

Please tell me more about any of the above answers that you wish.

* Required field