Teen Questionnaire

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Teen Questionnaire

Email *

Patient Name *

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious or on edge

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

2. Not being able to stop or control worrying

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

3. Worrying too much about different things

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

4. Trouble relaxing

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

5. Being so restless that it is hard to sit still

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

6. Becoming easily annoyed or irritated

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

7. Feeling afraid as if something awful might happen

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

Add total score from the GAD-7

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

When did the symptoms begin?

Name *

Modified for Adolescents (PHQ9-A)

Clinician

Date

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom put an "X" in the box beneath the answer that best describes how you have been feeling.

1. Feeling down, depressed, irritable, or hopeless?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

2. Little interest or pleasure in doing things?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

3. Trouble falling asleep, staying asleep, or sleeping too much?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

4. Poor appetite, weight loss, or overeating?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

5. Feeling tired, or having little energy?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

6. Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

7. Trouble concentrating on things like school work, reading, or watching TV?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you were moving around a lot more than usual?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself in some way?

0, Not at all
1, Several Days
2, More than half the days
3, Nearly every day

Add total score from PHQ9-A

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Has there been a time in the past month when you have had serious thoughts about ending your life?

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

CMRS, PARENT VERSION

Child's name *

Date of Birth

Case #/ ID#

INSTRUCTIONS: The following questions concern your child's mood and behavior in the past month. Please place a check mark or an 'x' in a box for each item. Please consider it a problem if it is causing trouble and is beyond what is normal for your child's age. Otherwise, check 'rare or never' if the behavior is not causing trouble. B Does your child:

1. Have periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling "on top of the world"

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

2. Feel irritable, cranky, or mad for hours or days at a time

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

3. Think that he or she can be anything or do anything (e.g., leader, best basket ball player, rap singer, millionaire, princess) beyond what is usual for that age

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

4. Believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

5. Need less sleep than usual; yet does not feel tired the next day

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

6. Have periods of too much energy

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

7. Have periods when she or he talks too much or too loud or talks a mile-a-minute

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

8. Have periods of racing thoughts that his or her mind cannot slow down, and it seems that your child's mouth cannot keep up with his or her mind

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

9. Talk so fast that he or she jumps from topic to topic

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

10. Rush around doing things nonstop

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

11. Have trouble staying on track and is easily drawn to what is happening around him or her

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

12. Do many more things than usual, or is unusually productive or highly creative

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

13. Behave in a sexually inappropriate way (e.g., talks dirty, exposing, playing with private parts, masturbating, making sex phone calls, humping on dogs, playing sex games, touches others sexually)

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

14. Go and talk to strangers inappropriately, is more socially outgoing than usual

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

15. Do things that are unusual for him or her that are foolish or risky (e.g., jumping off heights, ordering CDs with your credit cards, giving things away)

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

16. Have rage attacks, intense and prolonged temper tantrums

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

17. Crack jokes or pun more than usual, laugh loud, or act silly in a way that is out of the ordinary

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

18. Experience rapid mood swings

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

19. Have any suspicious or strange thoughts

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

20. Hear voices that nobody else can hear

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

21. See things that nobody else can see

0, NEVER/RARELY
1, SOMETIMES
2, OFTEN
3, VERY OFTEN

Add total score from CMRS