PANDAS Follow Up

Date *

Date

Patient Name *

First Name Last Name

PLEASE ANSWER WITH CURRENT SYMPTOMS ONLY

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

Intrusive and persistent obsessional worries (anxieties) about dirt and germs and related washing compulsions (circle obsessions and/or compulsions): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Intrusive and persistent obsessional worries (anxieties) about sexual or religious thoughts or behaviors and related rituals and compulsions: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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': *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Intrusive and persistent obsessional worries (anxieties) about collecting and hoarding: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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

PLEASE ANSWER WITH CURRENT SYMPTOMS ONLY

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

II. Associated Symptoms:

1. Anxiety Symptoms:

Separation anxiety - need to maintain proximity to person, a familiar location, or a thing: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

General anxiety: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Unfounded irrational fears and/or phobias: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Panic episodes: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

2. Emotional lability, depression:

Emotional lability - mood swings - moodiness: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Depression with or without suicidal or self-injurious thoughts: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

3. Increased irritability or aggressive behavior:

Increased irritability; defiant/irrational demands; reactive aggressive behavior, temper tantrums; rage attacks: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

4. Behavioral regression:

Behavioral regression ("baby talk," behavior atypical for actual chronological age): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Change in personality: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

5. School performance concentration/learning:

Difficulties in attention, concentration or learning - unable to concentrate or a clear problem with immediate or short term memory: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Loss of academic skills - especially math or in reading or writing: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Confusion: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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

6.A. Sensory symptoms:

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 (e.g. objects appear closer than they actually are): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

6.B. Hallucinations:

Visual or auditory hallucinations: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

6.C. Motor symptoms:

Dysgraphia (loss of ability to draw, copy figures and/or write letters): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Motoric hyperactivity and/or adventitious movements - kicking, spitting, flailing, rolling, or stomping (do not rate tics here); unable to stay still: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Piano playing finger movements: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Simple motor tics or vocal tics (grunting, squeaking, etc.): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Complex motor or vocal tics including; spitting, obscene words or actions, repeating words or actions changes in rate or pitch of speech: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

7.A. Urinary symptoms:

Urinary frequency or increased urge to urinate; daytime or night; inability to urinate: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

7.B. Sleep disturbance - fatigue:

Sleep problems (lengthy bedtime rituals, insomnia, inability to sleep; hypersomnia, nightmares): *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

Extreme tiredness or fatigue: *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

7.C. Dilated pupils:

Dilated pupils - "terror stricken look": *

0 - Absent 1 - Minimal 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme

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

PLEASE ANSWER WITH CURRENT SYMPTOMS ONLY

III. Impairment Rating:

Impairment (during the past week): *

None: 0 pts Minimal: 10 pts - 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: 30 pts - 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: 40 pts - Symptoms associated with major difficulties in self-esteem, family life, social acceptance, or school functioning Extreme: 50 pts - 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 scoial 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: