Skagit Pediatrics ONLINE Child Intake (4-15yrs)

This form is for parents to complete before the visit.

Please correct the errors described below.

Today's Date:

Parent's Name:

Patient's Name:

Birth date:

(MM/DD/YYYY)

Age:

We look forward to seeing you and your child.

Please complete this form and click submit. We will receive it in a safe and confidential way.

What questions or concerns would you like to discuss at your visit?

Pediatric Symptom Checklist-17 (PSC-17) (Ages 4-16) Parent

Instructions: Please mark under the heading that best fits your child.

1. Fidgety, unable to sit still

Never (A0) Sometimes (A1) Often (A2)

2. Feels sad, unhappy

Never (i0) Sometimes (i1) Often (i2)

3. Daydreams too much

Never (A0) Sometimes (A1) Often (A2)

4. Refuses to share

Never (E0) Sometimes (E1) Often (E2)

5. Does not understand other people’s feelings

Never (E0) Sometimes (E1) Often (E2)

6. Feels hopeless

Never (i0) Sometimes (i1) Often (i2)

7. Has trouble concentrating

Never (A0) Sometimes (A1) Often (A2)

8. Fights with other children

Never (E0) Sometimes (E1) Often (E2)

9. Is down on him or herself

Never (i0) Sometimes (i1) Often (i2)

10. Blames others for his or her troubles

Never (E0) Sometimes (E1) Often (E2)

11. Seems to be having less fun

Never (i0) Sometimes (i1) Often (i2)

12. Does not listen to rules

Never (E0) Sometimes (E1) Often (E2)

13. Acts as if driven by a motor

Never (A0) Sometimes (A1) Often (A2)

14. Teases others

Never (E0) Sometimes (E1) Often (E2)

15. Worries a lot

Never (i0) Sometimes (i1) Often (i2)

16. Takes things that do not belong to him or her

Never (E0) Sometimes (E1) Often (E2)

17. Distracted Easily

Never (A0) Sometimes (A1) Often (A2)

Food Security

Within the past 12 months, we were worried our food would run out before we got money to buy more.

Yes No

Within the past 12 months, the food we bought just did not last and we did not have money to get more.

Yes No

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