Parents' Questionnaire (Mental Health History) (Parent)

OMB No: ???: Exp Date: ???

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Parents’ Questionnaire

M any people have emotional problems at one time or another. We want to ask you about your own experience with emotional and behavioral problems and then about your child’s history. Remember that your answers are confidential. Your name does not appear on this form and no one outside the research team will know what you say. Please begin now. Thank you.

1. Have you ever had a period of time that lasted at least 2 weeks when you felt depressed (or down or blue)? Multiple symptoms of depression may include sadness, low energy, poor sleep (too little or too much), no appetite or too much appetite, not enjoying activities, or suicidal thoughts.			O Yes	O No
IF YES:	1a. How old were you when it first occurred?		year(s)
	1b. How many episodes have you had?
	1c. How long ago was the last episode?	O < 1 month O 1-6 months OR year(s) O 7-12 months
	1d. Have you ever been told by a doctor or other health professional that you have depression?		O Yes	O No
2. Have you ever had serious anxiety symptoms, such as:
2a. Panic attacks (shortness of breath, chest pain, numbness, tingling, sweating)?			O Yes	O No
2b. Feeling generally anxious for 6 months or more (excessive worrying, tension, feeling keyed up)?			O Yes	O No
3. Have you ever been told by a doctor or other health professional that you have:
3a. Post-Traumatic Stress Disorder (PTSD)?			O Yes	O No
3b. Obsessive Compulsive Disorder (OCD)?			O Yes	O No
4. Have you ever been told by a doctor or other health professional that you have Bipolar or Manic-Depressive Disorder?			O Yes	O No
5. Have you ever been told by a doctor or other health professional that you have Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)?			O Yes	O No

P

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).

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6. Have you ever heard voices talking to you or seen things other people could not hear or see?					O Yes	O No
7. Have you ever been treated by a psychiatrist or other mental health professional, such as a psychologist?					O Yes	O No
7a. If yes, what diagnosis did that person make?	O Depression O Bipolar or Manic Depressive Disorder O Generalized Anxiety O Panic Disorder O Obsessive-Compulsive Disorder (OCD) O Posttraumatic Stress Disorder (PTSD) O Attention-Deficit/Hyperactivity Disorder O Oppositional Defiant Disorder O Conduct Disorder O Borderline Personality Disorder O Schizophrenia or Schizoaffective Disorder O Other (Please Specify)___________________ O No diagnosis O Don’t Know
8. Have you ever received counseling for an emotional or behavioral problem?				O Yes		O No
8a. If yes, what was the problem?
9. Have you ever taken medication for an emotional problem?				O Yes		O No
9a. If yes, what is the name of the medication(s)?			O Prozac O Paxil O Zoloft O Effexor O Wellbutrin O Remeron O Lithium O Depakote O Tegretol O Neurontin O Topamax O Trileptal O Zyprexa	O Seroquel O Risperdol O Geodon O Haldol O Ritalin O Adderall O Concerta O Cylert O Clonidine O Strattera O Tenex O Other O Don’t Know
10. In general, would you say your health is:			O Excellent O Very Good O Good O Fair O Poor

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CHILD’s SIBLINGS

Now we would like to ask about your other children: (Please complete this section for each of your children who are not in the study. If you only have one child, skip this section)
Child #2: Age: ____years, Sex: o M o F
Please answer 13a, b, and c about child #2
11a. Has your child ever been treated by a psychiatrist or other mental health professional, such as a psychologist?		O Yes	O No
11b. If yes, what diagnosis did that person make?	O Depression O Bipolar or Manic Depressive Disorder O Generalized Anxiety O Panic Disorder O Obsessive-Compulsive Disorder (OCD) O Posttraumatic Stress Disorder (PTSD) O Attention-Deficit/Hyperactivity Disorder O Oppositional Defiant Disorder O Conduct Disorder O Borderline Personality Disorder O Schizophrenia or Schizoaffective Disorder O Other (Please Specify) _____________________________ O No diagnosis O Don’t Know
11c. Has your child ever received counseling for an emotional or behavioral problem?		O Yes	O No

Child #3: Age: ____years, Sex: o M o F
Please answer 14a, b, and c about child #3
12a. Has your child ever been treated by a psychiatrist or other mental health professional, such as a psychologist?		O Yes	O No
12b. If yes, what diagnosis did that person make?	O Depression O Bipolar or Manic Depressive Disorder O Generalized Anxiety O Panic Disorder O Obsessive-Compulsive Disorder (OCD) O Posttraumatic Stress Disorder (PTSD) O Attention-Deficit/Hyperactivity Disorder O Oppositional Defiant Disorder O Conduct Disorder O Borderline Personality Disorder O Schizophrenia or Schizoaffective Disorder O Other (Please Specify) _____________________________ O No diagnosis O Don’t Know
12c. Has your child ever received counseling for an emotional or behavioral problem?		O Yes	O No

Child #4: Age: ____years, Sex: o M o F
Please answer 15a, b, and c about child #4
13a. Has your child ever been treated by a psychiatrist or other mental health professional, such as a psychologist?		O Yes	O No
13b. If yes, what diagnosis did that person make?	O Depression O Bipolar or Manic Depressive Disorder O Generalized Anxiety O Panic Disorder O Obsessive-Compulsive Disorder (OCD) O Posttraumatic Stress Disorder (PTSD) O Attention-Deficit/Hyperactivity Disorder O Oppositional Defiant Disorder O Conduct Disorder O Borderline Personality Disorder O Schizophrenia or Schizoaffective Disorder O Other (Please Specify) _____________________________ O No diagnosis O Don’t Know
13c. Has your child ever received counseling for an emotional or behavioral problem?		O Yes	O No

Child #5: Age: ____years, Sex: o M o F
Please answer 16a, b, and c about child #5
14a. Has your child ever been treated by a psychiatrist or other mental health professional, such as a psychologist?		O Yes	O No
14b. If yes, what diagnosis did that person make?	O Depression O Bipolar or Manic Depressive Disorder O Generalized Anxiety O Panic Disorder O Obsessive-Compulsive Disorder (OCD) O Posttraumatic Stress Disorder (PTSD) O Attention-Deficit/Hyperactivity Disorder O Oppositional Defiant Disorder O Conduct Disorder O Borderline Personality Disorder O Schizophrenia or Schizoaffective Disorder O Other (Please Specify) _____________________________ O No diagnosis O Don’t Know
14c. Has your child ever received counseling for an emotional or behavioral problem?		O Yes	O No

FOR STUDY USE ONLY
ID Number		Gender
Date Interviewed	Month Day Year	Interviewed by

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