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CADDRA
SNAP-IV 26
GAD-7 & PHQ-9
WEISS
WFIRS-P
WFIRS-S
CADDRA
Start
CADDRA
SNAP-IV 26
GAD-7 & PHQ-9
WEISS
WFIRS-P
WFIRS-S
CADDRA
Phone
*
Please enter your phone number
Patient's first name
*
Please enter the patient's first name
Patient's last name
*
Please enter the patient's last name
Patient name (Combined)
*
Date of birth
*
Please enter patient's date of birth
/
/
Gender
*
Please enter patient's gender at birth
Choose One
Men
Female
Current date
*
/
/
Âge (Days)
*
Age
*
Role
What is your role?
A
Parents
B
Teacher
Role
What is your role?
A
Patient
B
Parents
C
Teacher
Role
What is your role?
A
Patient
B
Significant other or spouse
Role (Combined)
A
Parents
B
Teacher
C
Significant other or spouse
D
Patient
Respondent's name
*
Please enter your full name
Patient relationship
*
What is your relationship with the patient?
Choose One
Father
Mother
Friend
Co-worker
Other
Patient relationship
*
What is your relationship with the patient?
Choose One
Father
Mother
Other
Role and relationship (combined)
*
Medication
*
Are you currently taking any medication?
Choose One
Yes
No
Don't know
Current medication
*
What medication are you currently taking?
Symptoms in childhood
*
Did you know the patient as a child?
Choose One
Yes
No
School name
*
Please indicate the name of the school attended by the patient
Grade level
*
What is the patient's grade?
Class size
*
What is the class size?
Student status
*
What is his student status?
Choose One
Part-time
Full-time
N/A
How long have you known the patient
*
/
Number of hours with patient per day
*
Work
*
Do you have a job?
Choose One
Yes
No
Position
*
What position do you hold?
Employment status
*
Choose One
A
Full-time
B
Part-time
Studies
*
Are you a student?
Choose One
Yes
No
Field of study
*
What field are you studying in?
Student status
*
Choose One
A
Full-time
B
Part-time
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