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  • 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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