Fillable X Psychiatry Mine Parent(s) Other (Kaiser Permanente)

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X Psychiatry Mine Parent(s) Other (Kaiser Permanente)

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Psychiatry

Northern California

CPY ADOLESCENT QUESTIONNAIRE (12+)

MR #:

Name:

IMPRINT AREA

PREFERRED NAME

AGE PHONE

All responses are kept confidential (between you and your provider) unless you choose to

release this form to someone, or report that you are considering seriously harming

yourself or someone else, or someone has seriously harmed you or another child.

Please check the box or boxes that most closely describe you. Please use the blank lines to provide additional

information.

WHOSE IDEA WAS IT FOR YOU TO BE SEEN HERE TODAY?

 Mine  Parent(s)  Other

IF SOMEONE OTHER THAN YOU, ARE YOU OKAY WITH THIS IDEA?  No  Yes  Not sure

MAIN PROBLEM/MAJOR REASONS FOR SEEKING HELP AND WHEN THE PROBLEM BEGAN:

Please check the items below that are significant current problems for you.

Is it hard for you to focus and pay attention?



No (skip section)  Yes (complete items below)  



Make careless mistakes 



Problems paying attention/staying focused



Often do not finish homework or chores



Problems with organization



Lose things easily



Forgetful

Do you h

ave a hard time controlling your words or behaviors?

No (

skip section) Yes (complete items below)

Act

without thinking

Rest

less/Unable to sit still

Talk a lot

Probl

ems waiting my turn

Inter

rupt others

Are you feeling sad, depressed, or irritable?



No (skip section)  Yes (complete items below)



Sad or depressed mood



Irritable or grouchy



Problems sleeping (falling or staying asleep)



Tired a lot



Loss of interest, pleasure, or motivation

Are you often worried or anxious?

 No (skip section)  Yes (complete items below)

 Frequent headaches, stomachaches, or other pains

 Anxiety or worry (e.g., about past behaviors, future events,

doing well)

 Phobia or extreme fear (e.g., scared of flying, heights, going

over bridges)

 Thoughts/ideas that repeat over and over in your head



Behaviors that you feel that you have to do ov

er and over (e.g.,

counting, washing)

Are you often angry at others?



No (skip section)  Yes (complete items below)

 



Blame others for my mistakes



Angry most of the time



Easily annoyed by others



Go against adult requests or rules



Back talk or argue with adults



Enjoy “bugging” people



Lose temper

01996-113 (03-19)

PAGE 1 OF 4

Have you experienced or witnessed a traumatic event (i.e.,

car,

accident, death, earthquake)?

No (skip section) Yes (complete items below)

Ongoing n

egative thoughts about what happened

Ongoing n

egative feelings about what happened

Recur

rent distressing dreams about the event

Flashbacks about the event

Att

empts to avoid memories, thoughts, or feelings about what

happened



Psychiatry

Northern California

CPY ADOLESCENT QUESTIONNAIRE (12+)

MR #:

Name:

IMPRINT AREA

Do you do things that get you in trouble?



No (skip section)  Yes (complete items below)



Bully or threaten others



Get in physical fights



Hurt animals



Stole things



Set fire



Destroyed property



Broke into a house, building, car



Stay out all night



Ran away



Skip school



Problems with the law or police

Do you feel that you have a problem with eating or body

image?

 No (skip section)  Yes (complete items below)

 Fear of weight gain or being fat

 Trying to lose weight

 Unhappy with body weight or shape

 Purging/Self-induced vomiting

 Use of diet pills, laxatives, excessive exercise

 Overeat/Binge

 Feeling guilt, sadness, or disgust when I overeat

 Feeling that I cannot control my eating

Please describe the following current or past thoughts or feelings.

Never or

not at all

In the

past

Sometimes Often

All the

time

I hurt or injure myself on purpose.

  



I feel it is too painful to keep living or that I would be

better off dead.

  



I think about suicide.

  



I thought about specific ways to kill myself.

  



I tried to kill myself.

  



I think about hurting or killing others.

  



I hear voices or see things that are not there.

  



I feel like people are out to get me.

  



Please describe any current or past abuse.

Verbal Physical

Sexual

(put downs,

(hits, threatens

(pressured or

None

controlling) to hit)

forced)

CHILD ABUSE

  



WITNESSED VIOLENCE AT HOME

   

DATING VIOLENCE

   

PEER VIOLENCE (bullying)

   

ONLINE VIOLENCE (sexting, cyber-bullying)

   

01996-113 (03-19)

PAGE 2 OF 4



MR #:

Psychiatry

Northern California

Name:

CPY ADOLESCENT QUESTIONNAIRE (12+)

IMPRINT AREA

Please describe your substance use.

Never Past use only Rarely Weekly Daily

ALCOHOL     

TOBACCO     

MARIJUANA



OTHER DRUGS:

    

EXERCISE PER DAY (average)



30 min.



1-2 hours



3 hours or more

MEDIA USE PER DAY (average hours)

(e.g., social media, video games, phone, computer, TV)

 0  1-2  3-4  5 or more

CAFFEINE DRINKS PER DAY

(e.g.,

coffee, soda, energy drinks)

 0  1-2  3-4  5 or more

SLEEP PER NIGHT (average hours)



less than 5



6-7



8-10



11-12

Please describe your family (parents, step-parents, siblings) by completing the table below

NAME RELATIONSHIP

TO YOU

OUR RELATIONSHIP IS…

Poor Average Good

OVERUSES

DRUGS/ALCOHOL

SPENDS TIME

WITH ME

Example: Mary

Sister

 



 X

  

 

  

 

  

 

  

 

  

 

Please describe you and your relationships.

TOTAL NUMBER OF FRIENDS  None 

A few

 Average  A lot

NUMBER OF CLOSE FRIENDS

 0  1  2-3  4 or more

HOW I FEEL ABOUT MY FRIENDSHIPS

 Unsatisfied  Neutral  Satisfied

HOW I GET ALONG WITH PEERS



Poor



Average



Good

RELIGIOUS/SPIRITUAL SUPPORTS:

01996-113 (03-19)

PAGE 3 OF 4

___________________________________________________________________________________________________________

__________________________________

_________________________________________________________________________

___________________________________________________________________________________________________________

____________________________________________________________________________________________

__________________________________________________________________

__________________________

____________________________________________________________________________________________

_____________________________________

_______________________________________________________

____________________________________________________________________________________________

Psychiatry

MR #:

Northern California

Name:

CPY ADOLESCENT QUESTIONNAIRE (12+)

IMPRINT AREA



Please describe you and your relationships.

No Yes

DATING SOMEONE

 

SEXUALLY ACTIVE

 

PREGNANCY (PAST OR CURRENT)

 

SEXUAL ORIENTATION (e.g., straight, gay, bi): ___________________________________________________________

GENDER IDENTITY AND PREFERRED PRONOUN (e.g., boy, he, they): _________________________________________

SCHOOL NAME: ___________________________________________________ GRADE: _____________________

SCHOOL PERFORMANCE  Poor  Average  Above Average

SCHOOL PROBLEMS (check all that apply)

 Problems with teachers  Learning problems

 Referrals  Suspensions/Expulsions (# )

 Other school problems:

SCHOOL SUPPORTS (e.g., counselor, group, teacher):

What are you hoping to get out of being here (e.g., improve mood, help with anger, work on relationships)?

How important is this change for you? (Please circle a number.)

Not at all

Completely

01996-113 (03-19)

PAGE 4 OF 4

0 1 2 3 4 5 6 7 8 9 10

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X Psychiatry Mine Parent(s) Other (Kaiser Permanente)

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Completed 28 January 2022

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