Instructions: The items below refer to a recent injury experienced by your child. It works best if the child can answer the questions directed toward them.

1. Did you see the incident or accident where your child was hurt?

No
Yes

2. Were you with your child in an ambulance or helicopter on the way to the hospital?

No
Yes

3. When your child was hurt or you first of your child being hurt, did you feel really helpless? Like you wanted to make it stop happening, but you couldn't?

No
Yes

4. Does your child have any behavior problems or problems paying attention?

No
Yes

5. Was anyone other than your child hurt or killed with your child?

No
Yes

6. Child question: Was there a time when you didn't know where your parents were?

No
Yes

7. Child question: When you got hurt or right afterwards, did you feel really afraid?

No
Yes

8. Child question: When you got hurt or right afterwards, did you think you might die?

No
Yes

9. Did the doctor at the hospital tell you that your child suffered a fracture?

No
Yes

10. Is your child 12 years or older?

No
Yes

11. Is your child a girl?

No
Yes

 

Copyright 2003 Children's Hospital of Philadelphia. All rights reserved. Adopted from the 2003 article that appeared in the Journal of the American Medical Association, Screening for Risk of Persistent Posttraumatic Stress in Injured Children and Their Parents, Flaura K. Winston, MD, PhD; Nancy Kassam-Adams, PhD; Felipe Garcia-Espaņa, PhD; Richard Ittenbach, PhD; Avital Cnaan, PhD. For personal, research, or educational use only; other use may be prohibited by law.
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Last reviewed:
  On 7 Sep 2006
  By John M. Grohol, Psy.D.