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

Patient Name*

First NameLast Name
DOB*
Date of Appointment/ Fecha de su Cita*

MonthDayYear
Date
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?

YesNo
ASTHMA CONTROL TEST SCORE
TB RISK FACTORS
PHQ-9 (DEPRESSION SCREENING)
Little interest in doing things? [2 or more is positive]
Feeling down, depressed, or hopeless? [2 or more is positive]
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? [1 or more is positive]
CRAFFT SCREENING:
ANXIETY SCREENING: Total Score: 5-Mild Anxiety; 10-Moderate Anxiety, 15-Severe Anxiety [Further eval if 10 or more - do SCARED form and refer to psych]
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? 0:Not difficult at all, 1:Somewhat difficult, 2:Very difficult, 3:Extremely difficult
SUICIDE SCREENING: Number of "Yes" and "I dont want to answer" replies: 0=No intervention necessary; 1 or more: Ask question #5
Question #5: 1=patient has thoughts of killing self NOW
SDOH- EDUCATION Z55.6 – Problems related to health literacy (speaks other language at home)
SDOH- LIVING SITUATION PART 1 (1) Z59.811 – Housing instability, housed, with risk of homelessness (2) Z59.0 – Homelessness
SDOH- LIVING SITUATION PART 2 Z58 - Problems Related to Physical Environment
SDOH- FOOD Z59.4 – Lack of adequate food
SDOH- TRANSPORTATION Z59.64 Unable to pay for transportation for medical appointments or prescriptions
SDOH- UTILITIES Z59.62 Unable to pay for utilities
SDOH- SAFETY Z63 – Other problems related to primary support group, including family circumstances (Family) Z65 – Problems related to other psychosocial circumstances (others) -- 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.
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?*

	Not At All	Several Days	More than half the days	Nearly Everyday
1. Little interest or pleasure in doing things Poco interés o placer en hacer cosas
2. Feeling down, depressed, or hopeless Sintiéndose decaído(a), deprimido(a), o sin esperanzas
3. Trouble falling or staying asleep, or sleeping too much Dificultad en caer o permanecer dormido(a), o dormer demasiado

PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not At All	Several Days	More than half the days	Nearly Everyday
4. Feeling tired or having little energy Sintiéndose cansado o teniendo poca energía
5. Poor appetite or overeating Pobre de apetito o comer en exceso
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down Sintiéndose mal con usted mismo(a) – o que usted es un fracaso o qu ha quedado mal con usted mismo(a) o con su familia
7. Trouble concentrating on things, such as reading the newspaper or watching television Dificultad en concentrarse en cosas, tales como leer el periódico o ver televeisión
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual. ¿Moviéndose o hablando tan lento, que otras personas podrían notarlo? O lo contrario – muy inquieto(a) o agitado(a) que usted ha estado moviéndose mucho más de lo normal

PHQ-9 Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not At All	Several Days	More than half the days	Nearly Everyday
9. Thoughts that you would be better off dead or of hurting yourself in some way Pensamientos de que usted estaría mejor muerto(a) o de alguna manera lastimándose a usted mismo(a)

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?

	Not difficult at all/ Para nada difícil	Somewhat difficult/ Un poco difícil*	Very difficult / Muy difícil*	Nearly Everyday
Check One

THE CRAFFT SCREENING QUESTIONS

Part A: During the PAST 12 MONTHS, did you:

CRAFFT Part A: During the PAST 12 MONTHS, did you: *

	No	Yes
Drink any alcohol (more than a few sips)?
Smoke any marijuana or hashish?
Use anything else to get high? (anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”counter and prescription drugs, and things that you sniff or “huff”

CRAFFT If you answered NO to ALL of the questions in Part A, answer only number 1 below.*

	No	Yes
1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?

CRAFFT If you answered YES to ANY of the questions in Part A, answer ALL questions below.

	No	Yes
Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
Do you ever use alcohol or drugs while you are by yourself Alone?
Do you ever Forget things you did while using alcohol or drugs?
Do your Family and Friends ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into Trouble while you were using alcohol or drugs?

Tuberculosis Screen Questionnaire*

	Yes/Si	No
Has your child been exposed to anyone with the confirmed or suspected TB? ¿Su hijo(a) ha sido expuesto(a) a alguien que tenga o sospeche que tenga tuberculosis?
Has your child been exposed to any family member or close friend who has been in jail in the last five years? ¿A estado su hijo/a expuesto a algun miembro de la familia o a un amigo cercano que ha estado encarcelado los ultimos cinco años?
Has your child recently emigrated from Asia, the Middle East, Africa or Latin America? ¿Su hijo(a) ha emigrado de Asia, Medio Oeste, Africa o Latino America?
Has your child recently traveled to Asia, the Middle East, Africa or Latin America? ¿A viajado su hijo(a) recientemente a Asia, Medio Oeste, Africa o Latino America?
Does your child have HIV or live in a home with someone who has HIV? ¿ Tiene su hijo(a) SIDA o vive con alguien que tenga SIDA?
Has your child been exposed to anyone with HIV, homeless residents or nursing homes, teens or adults in jail, or migrant farm workers? ¿A estado su hijo (a) expuesto a alguien con SIDA, residente

Tuberculosis Screen Questionnaire*

	Yes	No
Have you (parent) emigrated with known TB status from Asia, the Middle East, Africa or Latin America; Do you travel to these areas or have contact in your home with people from these areas with known TB status? ¿A usted(s) (padres) emigrado con estado positivo de TB de Asia, Africa, Medio Oriente o Latino America? ¿Viaja usted a estas areas o tiene contacto en su casa con personas de estas areas con estado positivo de TB?
Does your child live in an area that you know to have a high prevalence of TB? ¿Vive su hijo(a) en una area que usted sabe ques sea de alto predomino de tuberculosis?
Does your child have diabetes, chronic renal failure, malnutrition, or a problem with the immune system that he/she was born with or acquired later in childhood? ¿Tiene su hijo(a) diabetes, insuficiencia renal crónica, desnutrición o un problema con el sistema immunológico con el que nació o adquirió en la infancia?

Over the last 2 weeks, how often have you been bothered by the following problems?*

	Not at all	Several Days	Over Half the Days	Everyday or Nearly everyday
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

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?

	Not difficult at all	Somewhat difficult	Very difficult	Extremely Difficult
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?

Ask the patient:*

	Yes	No	I dont want to answer
1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughtsabout killing yourself?
4. Have you ever tried to kill yourself?

If you answered "Yes" to question #4, HOW did you try to kill yourself?
If you answered "Yes" to question #4, WHEN did you try to kill yourself?

Answer this question only if you answered "YES" or "I dont want to answer" to any of the above questions.

	Yes	No
5. Are you having thoughts of killing yourself right now?

If yes, please describe:
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)

Yes / SiNo
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.

Yes / SiNo
I have a steady place to live // Tengo un lugar estable para vivir

Yes / SiNo

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*

	Yes/Si	No
Pests such as bugs, ants, or mice / Plagas como insectos, hormigas o ratones
Mold / Mojo
Lead paint or pipes / pintura o tuberías con plomo
Lack of heat / falta de calor
Oven or stove not working / El horno o la estufa no funcionan
Smoke detectors missing or not working / Faltan detectores de humo o no funcionan
Water leaks / fugas de agua
None of the above / Ninguna de las anterlores

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.*

	Often True/ A menudo es cierto	Sometimes true/ A veces es cierto	Never true/ Nunca cierto
3. Within the past 12 months, are you worried that your food would run out before you got money to buy more. // En los últimos 12 meses, se preocupó porque su alimentación se acabaría antes de que tuviera dinero para comprar más.
4. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. // En los últimos 12 meses, los alimentos que compró no alcanzaron o no tuvo dinero para comprar más

TRANSPORTATION/TRANSPORTE*

	Yes / Si	No
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? // ¿En los últimos 12 meses, la falta de un medio de transporte confiable le ha impedido acudir a citas médicas, reuniones, trabajo u obtener cosas necesarias para la vida diaria?

UTILITIES/UTILIDADES*

	Yes / Si	No	Already shut off / Ya apagado
6. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? // ¿En los últimos 12 meses la compañía de electricidad, gas, combustible o agua amenazó con cancelar los servicios en su hogar?

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.*

	Never/ Nunca	Rarely/ Casi nunca	Sometimes/ A veces	Fairly often/ Bastante a menudo	Frequently/ Frecuentemente
7. How often does anyone, including family and friends, physically hurt you? // ¿Cuán frecuente alguien, incluyendo su familia y amigos, la/lo lastiman físicamente?
8. How often does anyone, including family and friends, insult or talk down to you? // ¿Cuán frecuente alguien, incluida su familia y amigos, la/lo insulta o le habla con menosprecio?
9. How often does anyone, including family and friends, threaten you with harm? // ¿Cuán frecuente alguien, incluida su familia y amigos, la/lo amenaza con lastimarla/o?
10. How often does anyone, including family and friends, scream or curse at you? // ¿Cuán frecuente alguien, incluida su familia y amigos, le grita o la/lo maldice?

Education / Educación*

	Yes / Si	No
15. Do you speak a language other than English at home? / ¿Hablas otro idioma además del inglés en casa?

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?*

1 - All the time2 – Most of the time3 – Some of the time4 – A little of the time5 – None of the time
2. During the past 4 weeks, how often have you had shortness of breath?*

1 – More than once a day2 – Once a day3 – three to six times a week4 – once or twice a week5 – Not at all
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?*

1 – FOUR or more nights a week2 – TWO TO THREE nights a week3 – Once a week4 - Once or twice a month5 – Not at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?*

1 - THREE or more times per day2 – One to two times per day3 - Two to three times per week4 – Once a week or less5 – Not at all
5. How would you rate your asthma control during the past 4 weeks?*

1 - Not controlled at all2 – Poorly controlled3 – Somewhat controlled4 – Well controlled5 – Completely controlled
Should be Empty:

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 CRAFFT SCREENING QUESTIONS

1. What is your living situation today? // ¿Cuál es su situación de vivienda en la actualidad?