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Date of Visit?
B. Age of patient in years?
Please enter age between 6 and 26
C. Type of Visit? Choose one. [Well Child Check (WCC), Follow-Up Visit (FUV), New Patient Visit (NPV), Consult(CON)]
WCC
FUV
NPV
CON
D. Sex of patient assigned at birth? [Male (M) or Female (F)]
M
F
E. Gender identity of patient? [Male (M), Female (F), Transmale (TM), Transfemale (TF), Non-binary (NB), Didn't ask (DA)]
M
F
TM
TF
NB
DA
F. Did you administer a standardized rating tool to screen for mental health problems? [Yes (Y) or No (N)]
Y
N
G. Which rating tool did you use? (PSC-17, PSC-35, Other).
PCS-17
PCS-35
O
H. If you chose Other, what is the name of the standardized rating tool used?
I.Who completed this rating tool? [Caregiver (C), Youth (Y), or Both (B)]
C
Y
B
J. What was the PSC-17 screen result for the caregiver? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
K. What was the PSC-17 screen result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
L. What was the PSC-35 screen result for the caregiver? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
M. What was the PSC-35 screen result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
N. What was the Other screen result for the caregiver? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
O. What was the Other screen result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
P. Were the screening results / rating tool results documented in the medical record? [Yes (Y) or No (N)]
Y
N
Q. Do you have additional patients to enter? [Yes (Y) or No (N)]
Y
N
Congratulations!
You have entered 1 patient records. Please enter 19 records more to complete this dataset.
