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A. 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 assess symptoms of anxiety to inform intital diagnosis? [Yes (Y) or No (N)]
Y
N
G. Was a need identified by a screening tool (SC), parent concern (PC), or child concern (CC)?
SC
PC
CC
H. Which standard rating tool(s) did you use? [SCARED, GAD-7, Both (B), Other (O)]
SCARED
GAD-7
B
O
I. If you chose Other, what is the name of the standardized rating tool used?
J. Who completed this rating tool? [Caregiver (C), Youth (Y), or Both (B)]
C
Y
B
K. What was the SCARED result for the caregiver form? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
L. What was the SCARED result for the youth form? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
M. What was the GAD-7 result for the caregiver form? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
N. What was the GAD-7 result for the youth form?Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
O. What was the Other result for the caregiver form? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
P. What was the Other result for the youth form? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Q. Were the rating tool results documented in the medical record? [Yes (Y) or No (N)]
Y
N
R. 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.
