| 1 |
struct/resources |
mag18 |
Fewer than 2 people older than 18 years old |
| 2 |
struct/resources |
educ |
Caregiver’s highest education (check boxes) |
| 3 |
struct/resources |
statciv |
Patient’s parents’/guardians’ relationship status |
| 4c |
social support |
finsup |
Who can provide financial support |
| 4d |
social support |
supinf |
Who can provide information |
| 4b |
social support |
emotsup |
Who can provide emotional support |
| 4° |
social support |
childcare |
Who can provide childcare/parenting |
| 5 |
struct/resources |
transport |
Means of transportation |
| 7/8 |
struct/resources |
econdif |
current economic difficulties |
| 11° |
child problems |
pchangemood |
Change moods quickly? |
| 11b |
child problems |
pyounger |
Act younger than his/her age? |
| 11c |
child problems |
pupsetmd |
Get upset about going to the doctor/dentist |
| 11d |
child problems |
phyperactivy |
Act overly active? (i.e. hyperactivity |
| 11e |
child problems |
pattdiff |
Have attention difficulties/ADHD |
| 11f |
child problems |
pcry-upset |
Cry easily or become upset easily? |
| 11g |
child problems |
pdistracted |
Seem easily distracted? |
| 11h |
child problems |
pworry |
Worry? |
| 11i |
child problems |
plearndif |
Have learning or school difficulties? |
| 11j |
child problems |
psad |
Appear sad or withdrawn |
| 11l |
child problems |
pdevdelay |
Have developmental concerns or delays? |
| 11m |
child problems |
pshy |
Act shy or cling to you/other familiar adults? |
| 11n |
child problems |
ppeerdif |
Have difficulty making and keeping friends? |
| 11p |
child problems |
violence |
Been a victim of violence? |
| 13° |
family problems |
exec worry |
Has anyone experienced periods of excessive worry, fear and/or anxiety |
| 13b |
family problems |
subabuse |
Has substance use ever caused problems for anyone in the family? |
| 13c |
family problems |
saddness-depr |
Has anyone experienced periods of prolonged sadness or depression? |
| 13d |
family problems |
attentiondif |
Does anyone have difficulty focusing, concentrating and/or have a history of an attention deficit disorder? |
| 13e |
family problems |
maritaldif |
Have there been marital difficulties, conflict or discussion of separation? |
| 13g |
family problems |
alcoholprob |
Has anyone ever been told that s/he drinks too much? |
| 13h |
family problems |
childcustody |
Have there been any difficulties with child custody disputes? |
| 13j |
family problems |
psychprob |
Any other psychological conditions |
| 14° |
caregiver stress |
nightmares |
Have you had bad dreams or nightmares about your child being ill? |
| 14b |
caregiver stress |
anxiety |
Have you become jumpy since your child came to the hospital? |
| 14c |
caregiver stress |
overly reactive |
When you are reminded of your child being ill, do you sweat or tremble, or does your heart beat fast? |
| 15° |
family believes |
faithmd |
The doctors will know what to do |
| 15c |
family believes |
faithfam |
Our family will be closer because of this |
| 15f |
family believes |
faithtreatment |
We can make good treatment decisions |
| 15h |
family believes |
faithoutcome |
We’re going to beat this |
