Forms

These are forms that we ask you to fill out when you visit our office. Save time by printing these at home and filling them out in advance of your visit.

About the forms

The Pediatric Symptom Checklist (PSC) is a 35 point questionnaire that helps identify and assess changes in emotional and behavioral problems in children. The PSC is a widely used form that covers a broad range of emotional and behavioral problems and is meant to provide an assessment of psychosocial functioning. This form is given annually at each physical starting at age 6. The PSC is copyright © 2007 Mass General Hospital.

The Survey of Well-being of Young Children (SWYC)™ is a freely-available, comprehensive screening instrument for children under 5 years of age. The SWYC was written to be simple to answer, short, and easy to read. The entire instrument requires 15 minutes or less to complete and is straightforward to score and interpret. The SWYC is approved by MassHealth for compliance with the Children's Behavioral Health Initiative screening guidelines. The SWYC is copyright © 2010 Tufts Medical Center.

The Patient Health Questionnaire (PHQ-9) is a 9 question self administered instrument used to evaluate for depression. This is a screening tool which combines DSM-IV depression criteria with common depressive symptoms. It is given at each well visit starting at age 12 per American Academy of Pediatrics guidelines. The PHQ-9 is copyright ©1999 Pfizer Inc.

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