• SDOH-SWYC-FL-Asthma 12-21 yo Well Child Screening Forms

  • Date of Appointment/ Fecha de su Cita*
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    2 digit month, 2 digit day, 4 digit year
  • Does your child has asthma OR has your child used albuterol (inhaler or nebulizer machine) in the past 12 months? // ¿Ha utilizado su hijo el albuterol (inhalador o máquina de nebulización) en los últimos 12 meses?

  • A score of 11 or more when the numerical values for answers to questions 7-10 are added shows that the person might not be safe. // Una puntuación de 11 o más cuando se suman los valores numéricos de las respuestas a las preguntas 7 a 10 muestra que la persona podría no estar segura.

  • The following questionnaire consists of 9 statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. If several statements in the group seem to apply equally well, select the highest number for that group.

  • PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems?*
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  • PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems?*
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  • PHQ-9 Over the last 2 weeks, how often have you been bothered by any of the following problems?*
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  • PHQ-9 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Si usted marcó cualquiera de los problemas, ¿qué tan difícil han afectado estos problemas en hacer su trabajo, encargarse de tareas del hogar, o llevarse bien con otras personas?
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  • THE CRAFFT SCREENING QUESTIONS 

    Part A: During the PAST 12 MONTHS, did you:      
  • CRAFFT Part A: During the PAST 12 MONTHS, did you:      *
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  • CRAFFT If you answered NO to ALL of the questions in Part A, answer only number 1 below.*
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  • CRAFFT If you answered YES to ANY of the questions in Part A, answer ALL questions below. 
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  • Tuberculosis Screen Questionnaire*
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  • Tuberculosis Screen Questionnaire*
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  • Over the last 2 weeks, how often have you been bothered by the following problems?*
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  • If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
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  • Ask the patient:*
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  • Answer this question only if you answered "YES" or "I dont want to answer" to any of the above questions.
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  • 1. What is your living situation today? // ¿Cuál es su situación de vivienda en la actualidad?

  • I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)    //    No tengo un lugar estable para vivir (me estoy quedando temporalmente con otras personas, en un hotel, en un refugio, vivo en la calle, en la playa, en un automóvil, un edificio abandonado, en una estación de autobuses o tren, o en un parque)
  • I have a place to live today, but I am worried about losing it in the future    //   Actualmente tengo un lugar para vivir pero me preocupa perderlo en el futuro.
  • I have a steady place to live    //    Tengo un lugar estable para vivir
  • 2. Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY // Piense en el lugar donde vive. ¿Tiene alguno de los siguientes problemas? MARQUE TODAS LAS OPCIONES QUE CORRESPONDAN*
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  • FOOD/ALIMENTO: Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months. // Algunas personas han declarado lo siguiente con respecto a su situación alimentaria. Responda si las declaraciones fueron verdaderas FRECUENTEMENTE, A VECES o NUNCA para usted y su familia en los últimos 12 meses.*
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  • TRANSPORTATION/TRANSPORTE*
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  • UTILITIES/UTILIDADES*
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  • SAFETY: Because violence and abuse happens to a lot of people and affects their health we are asking the following questions. // SEGURIDAD: Estamos haciendo las siguientes preguntas dado que muchas personas sufren violencia o abuso y esto afecta su salud.*
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  • Education / Educación*
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  • 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?*
  • 2. During the past 4 weeks, how often have you had shortness of breath?*
  • 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness orpain) wake you up at night or earlier than usual in the morning?*
  • 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?*
  • 5. How would you rate your asthma control during the past 4 weeks?*
  • Should be Empty: