PANDAS Intake

Separation Anxiety - need to maintain proximity to person, a familiar location, or a thing

General Anxiety

Unfounded irrational fears and/or phobias

Panic episodes

Today's Date *

Date

Date of Onset

Date

Patient Name *

First Name Last Name

Name of Informant:

First Name Last Name

Relationship:

SYMPTOM SEVERITY RATING SCALE (Use these anchor points for each of the symptoms)

0 - NONE: No evidence of specific symptoms and behaviors

1 - MINIMAL: Specific symptoms and/or behaviors are present but are only evident occasionally and not a major source of difficulty

2 - MILD: Specific symptoms and/or behaviors are present during the past week, and are episodically a source of some distress and difficulty

3 - MODERATE: Specific symptoms and/or behaviors are present every day and are a source of distress and difficulty

4 - SEVERE: Specific symptoms and/or behaviors are present every day and are severe resulting in a great deal of distress and difficulty

5 - EXTREME Specific symptoms and/or behaviors are always present and are extremely severe resulting in an extreme degree of distress and difficulty

Please answer each question with these indicators:

"B" = Symptom severity BEFORE the onset of the first episode of illness or show of symptoms

"O" = Symptom severity during the week following the initial ONSET of symptoms or the worst symptoms have ever been if there is no specific onset date

"C" = CURRENT symptom severity during the past week

EACH ROW NEEDS TO HAVE A "B", "O" AND A "C"

Here is an example of the indicators:

I. CORE Obsessive-Compulsive Symptoms Use "BOC" indicators on EACH row. *

	0	1	2	3	4	5
Intrusive and persistent obsessional worries (anxieties) about dirt and germs and related washing compulsions (write obsessions and/or compulsions)
Intrusive and persistent obsessional worries (anxieties) about harm to self or others and related compulsions; a need to tell or confess (this symptom domain may be closely related to separation worries, but rate both if both are present)
Intrusive and persistent obsessional worries (anxieties) about sexual or religious thoughts or behaviors and related rituals and compulsions
Intrusive obsessional worries about symmetry and related compulsions: ordering, counting, or arranging; a need to touch, tap or rub, or a need for things to feel, look, or sound 'just right'
Intrusive and persistent obsessional worries (anxieties) about collecting and hoarding
Restrictive and/or avoidant food intake symptoms; Eating or feeding disturbance (including but not limited to apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; or concern about aversive consequences of eating) resulting in a refusal to eat (atypical anorexia) or a marked decrease in food intake
Miscellaneous. The need to know or remember; Fear of saying certain things; Fear of not saying just the right thing; Intrusive (non-violent) images; Intrusive sounds, words, music or numbers; Need to repeat activities (e.g. in/out of a doorway, up/down from chair); The need to involve another person (usually a parent) in ritual (e.g. asking a parent to repeatedly answer the same question; Mental rituals other than checking/counting; Excessive list making; Other (describe)*

*Describe Other:

Is there anything in this section that you would like to bring to the attention of your provider?

"B" = Symptom severity one week BEFORE the onsent of the first episode of illness

"O" = Symptom severity during the week following the initial ONSET of symptoms

"C" = CURRENT symptom severity during the past week

EACH ROW NEEDS TO HAVE A "B", "O" AND A "C"

II. Associated Symptoms

1. Anxiety Symptoms: *

2.) Emotional Lability, Depression: *

	0	1	2	3	4	5
Emotional lability - mood swings - moodiness
Depression with or without suicidal or self-injurious thoughts

3.) Increased Irritability or Aggressive Behavior: *

	0	1	2	3	4	5
Increased irritability; defiant/irrational demands; reactive aggressive behavior, temper tantrums; rage attacks

4.) Behavioral Regression: *

	0	1	2	3	4	5
Behavioral regression ("baby talk," behavior atypical for actual chronological age)
Change in personality

5.) School Performance Concentration/Learning: *

	0	1	2	3	4	5
Difficulties in attention, concentration or learning - unable to concentrate or a clear problem with immediate or short term memory
Loss of academic skills - especially math or in reading or writing
Confusion

"B" = Symptom severity one week BEFORE the onsent of the first episode of illness

"O" = Symptom severity during the week following the initial ONSET of symptoms

"C" = CURRENT symptom severity during the past week

EACH ROW NEEDS TO HAVE A "B", "O" AND A "C"

6.A.) Sensory Symptoms: *

	0	1	2	3	4	5
Heightened sensitivity to light, the way things "feel" (tags or labels) or "sound" or other sensory stimuli - such as smell or taste; a need to touch things in a specific way; how things "look" including spatial distortion (eg, objects appear closer than they actually are)

6.B.) Hallucinations: *

	0	1	2	3	4	5
Visual or auditory hallucinations

6.C.) Motor Symptoms: *

"B" = Symptom severity one week BEFORE the onsent of the first episode of illness

"O" = Symptom severity during the week following the initial ONSET of symptoms

"C" = CURRENT symptom severity during the past week

EACH ROW NEEDS TO HAVE A "B", "O" AND A "C"

7.A.) Urinary Symptoms: *

	0	1	2	3	4	5
Urinary frequency or increased urge to urinate; daytime or night; inability to urinate

7.B.) Sleep Disturbance - Fatigue: *

	0	1	2	3	4	5
Sleep problems (lengthy bedtime rituals, insomnia, inability to sleep; hypersomnia, nightmares)
Extreme tiredness or fatigue

7.C.) Dilated Pupils: *

	0	1	2	3	4	5
Dilated pupils - "terror stricken look" or "deer in headlights"

Is there anything in this section that you would like to bring to the attention of your provider?

Impairment Rating

Same as the above sections the impairment rating needs a "B", "O", and "C" in the right column as depicted below.

This rates how much symptoms have affected day-to-day life for you/the patient.

Here is an example of using the indicators with the Impairment Rating:

"B" = Symptom severity one week BEFORE the onsent of the first episode of illness

"O" = Symptom severity during the week following the initial ONSET of symptoms

"C" = CURRENT symptom severity during the past week

EACH ROW NEEDS TO HAVE A "B", "O" AND A "C"

III. Impairment Rating: *

	Score:
NONE
MINIMAL 10pts: Symptoms associated with subtle difficulties in self-esteem, family life, social acceptance, or school or job functioning (infrequent upset or concern about tics "vis a vis" the future, periodic, slight increase in family tensions because of symptoms; friends or acquaintances may occasionally notice or comment about symptoms in an upsetting way.)
MILD 20 pts: Symptoms associated with minor difficulties in self-esteem, family life, social acceptance, or school functioning.
MODERATE 30pts: Symptoms associated with some clear problems in self-esteem family life, social acceptance, or school or job functioning (episodes of dysphoria, periodic distress and upheaval in the family, frequent teasing by peers or episodic social avoidance, periodic interference in school performance because of PANS symptoms.)
SEVERE 40pts: Symptoms associated with major difficulties in self-esteem, family life, social acceptance, or school functioning.
EXTREME 50pts: Symptoms associated with extreme difficulties in self-esteem, family life, social acceptance, or school functioning (severe depression with suicidal ideation), disruption of the family (separation/divorce, residential placement), disruption of social ties (severely restricted life because of social stigma and social avoidance, removal from school.)

Is there anything in this section that you would like to bring to the attention of your provider?

*Based on the clinical experience of Susan Swedo, M.D., Miroslav Kovacevic, M.D., Beth Latimer, M.D., and James Leckman, M.D., with the help of Diana Pohlman, Keith Moore and many other parents.

**Six Obsessive-compulsive symptoms domains are presented. Rate all of them. Howevere, on the above tabel only enter the score of the most severe domain (times 3; 0-35)

***Seven Associated symptom domains are presented. Rate all of them. However, for each domain one or more symptom sets are listed. On the above table, only enter the score of the most severe symptom set for each domain (0-5).

Provider Notes: