Child Cross-Cutting Symptom Assessment (Level 1 Parent/Guardian Rated)

Assessment 1 of 28

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

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Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. During the past TWO (2) WEEKS, how much (or how often) has your child complained of stomachaches, headaches, or other aches and pains?
2. During the past TWO (2) WEEKS, how much (or how often) has your child said he/she was worried about his/her health or about getting sick? 0
3. During the past TWO (2) WEEKS, how much (or how often) has your child had problems sleeping—that is, trouble falling asleep, staying asleep, or waking up too early? waking up too early?
4. During the past TWO (2) WEEKS, how much (or how often) has your had problems paying attention when he/she was in class or doing his/her homework or reading a book or playing a game?
5. During the past TWO (2) WEEKS, how much (or how often) has your had less fun doing things than he/she used to?
6. During the past TWO (2) WEEKS, how much (or how often) has your seemed sad or depressed for several hours?
7. During the past TWO (2) WEEKS, how much (or how often) has your seemed more irritated or easily annoyed than usual?
8. During the past TWO (2) WEEKS, how much (or how often) has your seemed angry or lost his/her temper?
9. During the past TWO (2) WEEKS, how much (or how often) has your started lots more projects than usual or did more risky things than usual?
10. During the past TWO (2) WEEKS, how much (or how often) has your slept less than usual for him/her, but still had lots of energy?
11. During the past TWO (2) WEEKS, how much (or how often) has your said he/she felt nervous, anxious, or scared?
12. During the past TWO (2) WEEKS, how much (or how often) has your not been able to stop worrying?
13. During the past TWO (2) WEEKS, how much (or how often) has your said he/she couldn’t do things he/she wanted to or should have done,because they made him/her feel nervous?
14. During the past TWO (2) WEEKS, how much (or how often) has your said that he/she heard voices when there was no one there speakingabout him/her or telling him/her what to do or saying bad things to him/her?
15. During the past TWO (2) WEEKS, how much (or how often) has your said that he/she had a vision when he/she was completely awake that is,saw something or someone that no one else could see?
16. During the past TWO (2) WEEKS, how much (or how often) has your said that he/she had thoughts that kept coming into his/her mind that he/she would do something bad or that something bad would happen to him/her or to someone else?
17. During the past TWO (2) WEEKS, how much (or how often) has your said he/she felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?
18. During the past TWO (2) WEEKS, how much (or how often) has your seemed to worry a lot about things he/she touched being dirty or having germs or being poisoned?
19. During the past TWO (2) WEEKS, how much (or how often) has your said that he/she had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening?
20. In the past TWO (2) WEEKS, has your child had an alcoholic beverage (beer, wine, liquor, etc.)?
21. In the past TWO (2) WEEKS, has your child smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco?
22. In the past TWO (2) WEEKS, has your child Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
23. In the past TWO (2) WEEKS, has your child Used any medicine without a doctor’s prescription (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)?
24. In the past TWO (2) WEEKS, has he/she talked about wanting to kill himself/herself or about wanting to commit suicide?
25. In the past TWO (2) WEEKS, has he/she talked has he/she EVER tried to kill himself/herself?