CDEs
Forms
Substance Abuse Prescription Illicit Substance Over the Counter Product Family Neglect Personal Medical History Yes No Indicator
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Poor Appetite or Overeating Score 4 Point Scale
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Trouble Sleeping Score 4 Point Scale
PROMIS Parent Proxy Short Form 8 Pain Interference v1.0 Pf2pain2 Past 7 Days Child Had Trouble Doing Schoolwork When in Pain Score 5 Point Scale
Substance Abuse Prescription Illicit Substance Over the Counter Product Personal Medical History Yes No Indicator
Fagerstrom Test Cigarettes Per Day Score
Gender Code
Fagerstrom Test Impaired Health Smoking Score
Fagerstrom Test Difficulty Stop Public Smoking Score
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Thoughts You Would be Better Off Dead or Hurting Yourself Some Way Score 4 Point Scale
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Feel Depressed Score 4 Point Scale
PROMIS Pediatric Short Form 8a Pain Interference v1.0 2180R1 Past 7 Days Hard to Stay Standing When in Pain Score 5 Point Scale
Patient Alcohol Consumption Past Year Morning Drink Frequency
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Feel Tired Score 4 Point Scale
Timeline Followback Method Illicit Substance Hallucinogens MDMA/Ecstasy Assessment Yes No Indicator
Patient Alcohol Consumption Past Year Failure Performing Responsibility Frequency
Patient Health Questionnaire (PHQ-9) Last Two Weeks How Often Feeling Bad about Yourself or Feeling Like a Failure or Have Let Yourself or Your Family Down Score 4 Point Scale
PROMIS Adult Short Form 6b Pain Interference v1.0 PAININ10 Past 7 Days How Much Did Pain Interfere with Enjoyment of Recreational Activities Score 5 Point Scale
PROMIS Parent Proxy Short Form 8 Pain Interference v1.0 Pf2pain5 Past 7 Days Child Had Trouble Sleeping When in Pain Score 5 Point Scale
PROMIS Adult Short Form 6b Pain Interference v1.0 PAININ14 Past 7 Days How Much Did Pain Interfere with Doing Tasks Away from Home Score 5 Point Scale
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