Fillable Form 4: n Psychiatry PEDIATRIC OUTCOMES QUESTIONNAIRE POQ (Kaiser Permanente)

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Form 4: n Psychiatry PEDIATRIC OUTCOMES QUESTIONNAIRE POQ (Kaiser Permanente)

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Please answer each item by
circling one number per row.
In the past 7 days...
1. My child felt sad. 0 1 2 3 4
2. My child felt alone. 0 1 2 3 4
3. It was hard for my child to have fun. 0 1 2 3 4
4. My child could not stop feeling sad. 0 1 2 3 4
5. My child felt like he/she couldn’t do anything right. 0 1 2 3 4
6. My child felt everything in his/her life went wrong. 0 1 2 3 4
Sum of items 1 – 6
n
7. My child felt scared. 0 1 2 3 4
8. My child felt like something awful might happen. 0 1 2 3 4
9. My child felt nervous. 0 1 2 3 4
10. My child felt worried. 0 1 2 3 4
Sum of items 7 – 10
n
11. My child felt mad. 0 1 2 3 4
12. My child felt upset. 0 1 2 3 4
13. My child was so angry he/she felt like yelling at somebody. 0 1 2 3 4
Sum of 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
Goodness of Fit: Sum of items 1 – 3
n
PEDIATRIC OUTCOMES QUESTIONNAIRE – POQ 2.0
Parent/Caregiver Version (for ages 5 – 17)
Never
Almost
Never
Sometimes
Often
Almost
Always
Not at all
Only a
Little
Sometimes
Quite a Bit
Completely
PLEASE WAIT until your clinician asks you to
complete these items.
01996-100 (1-17) SPANISH ON REVERSE, FOR CHINESE USE -102
IMPRINT AREA
MR #:
Name:
DATE CHILD NAME
RELATIONSHIP TO CHILD
Northern California
n Psychiatry
4
Por favor, conteste cada frase encerrando con
un círculo un número por línea.
En los últimos 7 días…
1. Mi niño/a se sintió triste. 0 1 2 3 4
2. Mi niño/a sintió que estaba solo/a. 0 1 2 3 4
3. A mi niño/a le fue difícil divertirse. 0 1 2 3 4
4. Mi niño/a no pudo dejar de sentirse triste. 0 1 2 3 4
5. Mi niño/a sintió que no podía hacer nada bien. 0 1 2 3 4
6. Mi niño/a sintió que todo le salía mal en la vida. 0 1 2 3 4
Suma de las líneas 1 al 6 =
n
7. Mi niño/a sintió miedo. 0 1 2 3 4
8. Mi niño/a sintió como si algo terrible pudiera pasar. 0 1 2 3 4
9. Mi niño/a se sintió nervioso/a. 0 1 2 3 4
10. Mi niño/a se sintió preocupado/a. 0 1 2 3 4
Suma de las líneas 7 al 10 =
n
11. Mi niño/a se sintió enojado/a. 0 1 2 3 4
12. Mi niño/a se sintió molesto/a. 0 1 2 3 4
13. Mi niño/a estuvo tan enojado/a que tenía ganas de gritarle a alguien. 0 1 2 3 4
Suma de las líneas 11 al 13 =
n
Valoración global de malestar emocional (SUMA de las tres casillas anteriores) =
n
1. Hablé de lo que quería. 0 1 2 3 4
2. Me sentí verdaderamente comprendido. 0 1 2 3 4
3. Entiendo y estoy de acuerdo con el plan sobre lo que se va hacer. 0 1 2 3 4
Bondad de ajuste: Suma de las líneas 1 al 3 =
n
Nunca
Casi
nunca
A veces
A menudo
Casi
siempre
Para nada
Sólo un
poco
A veces
Bastante
Por
completo
Por favor, espere hasta que su profesional clínico
le pida que complete esta sección..
01996-101 (1-17) REVERSE
IMPRINT AREA
MR #:
Name:
PARENTESCO CON EL NIÑO O LA NIÑA / RELATIONSHIP TO CHILD
CUESTIONARIO DE RESULTADOS PEDIÁTRICOS – POQ 2.0
Padre, madre o tutor (5 – 17 años)
PEDIATRIC OUTCOMES QUESTIONNAIRE — POQ
Parent/Caregiver Version (for ages 5 – 17)
Norte de California / Northern California
n Psiquiatría /
Psychiatry
4
FECHA / DATE NOMBRE DEL NIÑO O DE LA NIÑA / CHILD NAME
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Form 4: n Psychiatry PEDIATRIC OUTCOMES QUESTIONNAIRE POQ (Kaiser Permanente)

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Completed 5 May 2022

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