!"#$%&'(!#)$*+,-.,# /01 $%&$(#2)#!"#$%&3+(4#*+,$56(789:
(Pediatric ACEs and Relevant Life Events Screener) (PEARLS) – -;#0%<:%&79:=>?#/0!-4,:/<:'(@C
(Teen Caregiver Report)
.9 19
Teen (Parent/Caregiver Report) – Deidentified
!"#$%&'#()*+,-./012-30-456(78$41$
!"#$%&'()*+#:
,*-./"0: !"#.
/*'#1%.0/:
,*-&'($23#: 4!3
)5637"#0"8./"0:
"<%;=29-2>(?1@>-$)-!"#$%&3+(4#*+,!A)#B"C26#. !DE,9!(0%F5%&'? ?1@>-$%&!"<>,%&+G@%D%#@:F>&$1*>-H.,@I71J%- /01
3+(4#$%&!?)&KLM79:0L$79:*5%&'#. J($!A>%K%$N%D*5%&$56($)-0L$79:*5%&
!JE,9(5%J($!A>%@%D%#35(;B"C!7>%!O>G%D@I71J%-*+,#+!*>,%*+,!?)&'?'#.
>,
C
+ C
B&35(:!(0%B#$.H%D&)-H)G:/HM0L$79:*5%&!$+#D%, 0
L$79:*5%&'#C!")& " '#CKLM&.%B&!(0%*+,?1@>-$%&#:H.,'?&+G!$+#7PG&"<E-?
$10I&%0(D!9>%?1@-$%&*+,F5%&D% /01 ?1OI-)&. !"#$%&'()*!+, ,&)-.&/&00123&4!56&789)'65%:19;4!+<54 “2.”
/<&'65%>+?!.@&0AB)-.&/&0/=!@B,56& “;0C%,” ;#D5-.&@B,'.&#(,-.&/&0:()EF+;0C% “;0C%.”
<E ), .,
> 3=
ພາກທ 1
!"#$%&'()*+,-.%)/01"2#3456789/:<"8!+4=7&8.&:";'-7+$>?),@#ABC4?
'()*,=<D)!"#$%&'()*+,-.E";0F#D()467/<;E34#)*0GH340GH"*, 467/<;E34,D)9E3# 8!G/A 467/<;E4#)*I>#I;%&ABC4?
!"#$%&'()*+,-.%)/01"2#3456789/:";<"8!+4=7&8.&:";'-79-43*A)0@$G5)4J=<ABC4? (K>D12)&: LM#NF9+0>?), LM#J=<, LM#/4L5!)M, PTSD, A LM#D=K>##3&D>*)
56789/:";<"8!+4=7&8.&+,-.O=7*IGO)<, +E3<PA;%34%). A <"Q"#!"#$%&'()*ABC4?
567892,-&$%&+<3# A :";<"8!+4&8.&P<HF7&+,-.9 A P*IGJ@43*9-43*A)#(RD#34#)*<C79+AB>?), #)*PN;1)+04K=< A 1)I=7*I>DK)9P4037&85<AB).+#-*/IABC4?
!"#$%&'()*+,-.$)<#)*<"8!+4=7&8.&'+O)G0>9L<.:";<"8!+4=7&8.&P<HF7& (.>#K>D12)&: 467/<;E34#)*I>#I;%&J)#0GQ)*G#)*'-74I%</5 A
467/<;E34#)*<"8!+4=7&8.&P*+D!)'-7+J34I2D. A /<;E344)<+J34+Q=&892*P*+D!)'0)9)<N(D.+ABC%/<#6K)9) ABC4?
BC 2 2 BC 67 ຼື 3 BC
2 - BC 67
!"#$%&'()*+,-.+A3* A /<;.=*56789/:";<"8!+4=7&8.&QC#:";PA.(,>*%C7*ES%&P0, I;%.<(), O=7*IGO)< A +E3<PA;%34%).ABC4? ຫ !"#$%&'()*+,-.+A* A
/<;.=*56789/:";<"8!+4=7&8.&QC#K>4K, +KG, N># A +E3<PA;4)<+J34<SD.%)D@<ABC4?
9-:";PA.(P<HF7&P*,>D+EC%*
., .)<, K>4K A 8#D(&4)&0=7&4)&12)&P02!"#$%&'()*1+!C?%.T4? ຫ
9-:";PA.(P<HF7&P*,>D+EC%*+,-.K-!"#$%&'()*12)&E@*8E&J>*D()!"#$%&')*9-8I;D A /<;E344)<+J344? ຫ
9-:";PA.(P<HF7&P*,%4,>D+,-.$>79$"2!"#$%&'()* A #G'6)P*D='-#)*'-7+E3<PA;!"#$%&'()*1;)*#DD()+$>)+J>?)%)<JGQ#+E3<PA;+J344?
"; - BC "2 6 ຼື
( BC 6 ຼື
BC > C 6
6 BC
BC "; BC BC 3
BC 2 BC 67
!"#$%&'()*+,-.IG0>4#34#)*!(D&!G+9-<')&+5<4? K>D12)&: 9-:";P<:";HF7&/<;J344).!"#$%&'()* A
$6PA;!"#$%&'()*J344).4@#,>*P*E"4844'-7467KS%&#)*, A +E3<PA;!"#$%&'()*E0F#4670G4).PJ, A 9-:";P<:";HF7&+,-.5G.).)9 A /<;9-+5<06)5*')&I)#,
E"'GD)*, A N(%&,%<#34!"#$%&'()*1)&8';J=&8!;DA4?
+,-.9-#)*I2R*8I&'-706),3*P*0GQ)*G,D)906)53*$%&:";<"8!+4=7&8.&+<3#*S%.ABC4? K>D1
2)&: 56789/:";<"8!+4=7&8.&/<;9-#)*A12)ES)& A 8.#')*, A
,"2E3#/<;.S).+$>?) A .S).%%#4?
*5%&'#CH9-O)$2.%N%D(5% ''/DM&'' B@MJ%$* 1?
!"#$%&'=,@.97<&@GH'.&#(,-.&/&0:4()*23=B.
Laotian'2020'
+
> AB
%+
%
+