1. I felt sad. 0 1 2 3 4
2. I felt alone. 0 1 2 3 4
3. It was hard for me to have fun. 0 1 2 3 4
4. I could not stop feeling sad. 0 1 2 3 4
5. I felt like I couldn’t do anything right. 0 1 2 3 4
6. I felt everything in my life went wrong. 0 1 2 3 4
Sum of circled numbers for items 1 – 6
n
7. I felt scared. 0 1 2 3 4
8. I felt like something awful might happen. 0 1 2 3 4
9. I felt nervous. 0 1 2 3 4
10. I felt worried. 0 1 2 3 4
Sum of circled numbers for items 7 – 10
n
11. I felt mad. 0 1 2 3 4
12. I felt upset. 0 1 2 3 4
13. I was so angry I felt like yelling at somebody. 0 1 2 3 4
Sum of circled numbers for items 11 – 13
n
Global Distress Score (TOTAL of three boxes above) =
n
1. I talked about what I wanted. 0 1 2 3 4
2. I felt really understood. 0 1 2 3 4
3. I understand and agree with the plan about what to do. 0 1 2 3 4
Sum of items 1 – 3
n
Never
Almost
Never
Sometimes
Often
Almost
Always
Not at all
Only a
Little
Sometimes
Quite a Bit
Completely
Please answer each item by
circling one number per row.
In the past 7 days...
01996-103 (1-17)
IMPRINT AREA
MR #:
Name:
ENCOUNTER DATE CLINICIAN: FIRST NAME, LAST NAME
PEDIATRIC OUTCOMES QUESTIONNAIRE – POQ 2.0
Youth Version (for ages 8 – 17)
PLEASE WAIT until your clinician asks you
to complete these items.
Northern California
n Psychiatry
4
