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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 suicidality? [Yes (Y) or No (N)]
Y
N
G. Which standard rating tool(s) did you use? [PHQ-9, ASQ, Other (O)]
PHQ-9
ASQ
O
H. If you chose Other, what is the name of the standardized rating tool used?
Please choose your answer
I.Who completed this rating tool? [Caregiver (C), Youth (Y), or Both (B)]
C
Y
B
Please choose your answer
J. What was the PHQ-9 result for the caregiver? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Please choose your answer
K. What was the PHQ-9 result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Please choose your answer
L. What was the ASQ result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Please choose your answer
M. What was the Other screen result for the caregiver? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Please choose your answer
N. What was the Other screen result for the youth? Choose one. [Positive (P), Negative (N), Not Administered (NA)]
P
N
NA
Please choose your answer
O. Were the screening results / rating tool results documented in the medical record? [Yes (Y) or No (N)]
Y
N
Please choose your answer
P. Do you have additional patients to enter? [Yes (Y) or No (N)]
Y
N
Please choose your answer
Congratulations!
You have entered 3 patient records. Please enter 17 records more to complete this dataset.
