Fillable (Pediatric ACEs and Relevant Life Events Screener) (PEARLS) (ACEs Aware)

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(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) (ACEs Aware)

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        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) –  (Child)

 :


: :


 : 
 :
    
  

        
       
       
           
   
         
  
“”  

 “”
 “”




1
  
  /     
    
    /   
  
  /       (   

     PTSD
  )
/       
         
    

   
      (  
    
          ) 
      /     
         
     /            
         
      
            
                
       
          
   
     
      
  
   
      
/       
    
 “”

:
 
 
Child (Parent/Caregiver Report) – Deidentified
Thai 2020
2
               (   
  
       )
    (   
     
       

 


           ) 
 
       
(  
        

          
  
)
           

  
         

 
  
  /          
  
     

 
 “”

 :
Child (Parent/Caregiver Report) – Deidentified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) –
 (Child)

 :


: :


 : 
 :
   
    
  

        
       
       
           
   
         
  
“”  “”
 “”


 
1
 “”

  
  /     

☐ 
☐
    
    /   

☐ 
☐
  
  /        (   

  
  PTSD   )

☐ 
☐
/       

☐ 
☐
         
   


   

☐ 
☐
      (  
    
          ) 

☐ 
☐
       /     
         
     /            

☐ 
☐
         
     
            
                 

☐ 
☐
       
          
   
     
  
   

☐ 
☐
  
   
       
/            

☐ 
☐
    “”
 
 
 
Child (Parent/Caregiver Report) – Identified
Thai 2020
2
 “”

              (   
          )

☐ 
☐
    (   
     
       

 

    
     ) 

☐ 
☐
 
       
(  
   
    
        
  
   
)

☐ 
☐
           

  

☐ 
☐
         

  

☐ 
☐
  
  /          

☐ 
☐
  
     

 

☐ 
☐
    “”
  
Child (Parent/Caregiver Report) – Identified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) – 
   (Teen Caregiver Report)

 :


: :


 : 
 :
   
    
  

        
       
    
     
     
   
         

“”  

 “”
 “”




1
  
  /     
    
    /  
  
  /        (  

     PTSD
  )
/  
    
         
    

   
      (  
    
         ) 
       /     
         
      /           
         
      
            
                 
       
          
   
     
       
  

  
       
/       
     
 “”

:
 
 
Teen (Parent/Caregiver Report) – Deidentified
Thai 2020
2
              (  
  
       )
   
(  
      
       

 


           ) 
 

       
( 
        

          
  
)
       
   

   
         

  
  
  /          
  
    

       
          (  
 )
 “”

 :
Teen (Parent/Caregiver Report) – Deidentified
T
hai 2020
        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) – 
    (Teen Caregiver Report)

 :


: :


 : 
 :
   
    
  

        
       
       
           
   
         
  
“”  

 “”
 “”



1
 “”

  
  /     

☐

☐
    
    /   

☐

☐
  
  /        (  

  
  PTSD   )

☐ 
☐
/       

☐

☐
         
   


   

☐ 
☐
      (  
    
          ) 

☐ 
☐
       /     
         
      /           

☐ 
☐
         
      
            
                 

☐ 
☐
       
          
   
     
  
   

☐ 
☐
  
   
       
/       
     

☐ 
☐
    “”
 
 

 
Teen (Parent/Caregiver Report) – Identified
Thai 2020
2
 “”

              (  
          )

☐ 
☐
    (  
      
       




            ) 

☐ 
☐


       
(  
   
    
        
  
  
)

☐ 
☐
           

   

☐

☐
         

  

☐ 
☐
  
  /          

☐

☐
  
     

 

☐

☐
       

☐ 
☐
          (  
 )

☐

☐
    “”
 
Teen (Parent/Caregiver Report) – Identified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events  (  ) (Teen (Self Report))

 
 

   
    
  

       
     
    
        
    
        “”
 “”
 “”

  



 
1
 
  /    
 
     /   
 
  /        (  

     PTSD
  )
  / 
       
            
    

   
     (  
    
          ) 
     /     
         
     /            
     
   
    
         
            
       
           

    
      
  

  
        
/       
    
 “” :
 

 
Teen (Self Report) – Deidentified
Thai 2020
2
              (  
    
      )
   (
 
    
       

 


          ) 
 

      
(  
        

          
  
)
         
  /   


        

 
 
  /           
 
     

 
       
        (  
 )
 “”

 :
Teen (Self Report) – Deidentified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events  (  ) (Teen (Self Report))

 


 
   
    
  

       
     
         
        
    
        “”
 “”
 “”




 
1
 “”

 
  /    

☐

☐
 
     /   

☐

☐
 
  /       (  

    
PTSD   )

☐ 
☐
  /         

☐

☐
            
  


   

☐ 
☐
      (  
    
          ) 

☐ 
☐
     /     
         
     /            

☐ 
☐
        
    
          
            

☐ 
☐
       
       
   
     
       

☐ 
☐
  
   
        
/            

☐ 
☐
    “”
 
 
 
Teen (Self Report) – Identified
Thai 2020
2
 “”

              (  
          )

☐ 
☐
   (  
    
       

 


           ) 

☐ 
☐
 

      
(  
        

          
  
)

☐ 
☐
            /   



☐

☐
        

 

☐

☐
 
  /          

☐

☐

     

 

☐

☐
      

☐

☐
        (  
 )

☐

☐
    “”
 
Teen (Self Report) – Identified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) –
 (Child)

 :


: :


 : 
 :
    
  

        
       
       
           
   
         
  
“”  

 “”
 “”




1
  
  /     
    
    /   
  
  /       (   

     PTSD
  )
/       
         
    

   
      (  
    
          ) 
      /     
         
     /            
         
      
            
                 
       
          
   
     
      
  
   
     
/       
     
 “”

:
 
 
Child (Parent/Caregiver Report) – Deidentified
Thai 2020
2
 “”

              (   
          )

☐ 
☐
    (   
     
       

 

    
     ) 

☐ 
☐
 
       
(  
   
    
        
  
   
)

☐ 
☐
           

  

☐ 
☐
         

  

☐ 
☐
  
 /         

☐ 
☐
  
     

 

☐ 
☐
 “”

 :
Child (Parent/Caregiver Report) – Identified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) – 
    (Teen Caregiver Report)

 :


: :


 : 
 :
        
  

        
       
     
    
     
   
         

“”  

 “”
 “”




1
  
  /     
    
    /  
  
 /        (  

     PTSD
  )
/  
     
          
    

   
      (  
    
         ) 
       /     
         
      /           
      
   
      
            
                 
       
          
   
     
       
  

  
       
/       
     
   “ ”
 
 
 
Teen (Parent/Caregiver Report) – Deidentified
Thai 2020
2
 “”

             (  
          )

☐ 
☐
    (  
      
       


            ) 


☐ 
☐


       
(  
   
    
       
  
  
)

☐ 
☐
           

   

☐

☐
        

  

☐ 
☐
  
  /          

☐

☐
  
     

 

☐

☐
       

☐ 
☐
          (  
 )

☐

☐
    “”
 
Teen (Parent/Caregiver Report) – Identified
Thai 2020
        
  
(Pediatric ACEs and Relevant Life Events  (  ) (Teen (Self Report))

 


 
   
    
  

       
     
    
        
    
        “”
 “”
 “”

  



 
 1
 
  /    
 
     /   
 
  /        (  

    PTSD
  )
  / 
       
            
    

   
     (  
    
          ) 
     /     
          
     /            
     
   
    
         
             
       
           

    
      
  

  
        
/       
    
    “”
 
 
 
Teen (Self Report) – Deidentified
Thai 2020
2
 “”

              (  
          )

☐ 
☐
   (  
    
       

 


           ) 

☐ 
☐
 

      
(  
        

        
  
)

☐ 
☐
            /   



☐

☐
       

 

☐

☐
 
  /          

☐

☐

     

 

☐

☐
      

☐

☐
        (  
 )

☐

☐
    “”
 
Teen (Self Report) – Identified
Thai 2020
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(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) (ACEs Aware)

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Completed 19 May 2021

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