Screening Tools

Validated instruments used at Bright Futures and adult preventive visits. MDCalc links use peer-reviewed scoring; canonical instruments are also linked for the printable form.

Depression & anxiety

• PHQ-9 (MDCalc) — 9-item depression screen; Kroenke 2001 J Gen Intern Med. Score ≥10 indicates probable major depression.
• PHQ-2 (MDCalc) — first 2 PHQ-9 items as a screening preamble; positive prompts the full PHQ-9.
• PHQ-A (Adolescent PHQ, 11–17 yr) — AAP/GLAD-PC depression screen for adolescents; printable PDF.
• GAD-7 (MDCalc) — 7-item generalized anxiety screen; Spitzer 2006 Arch Intern Med.
• Edinburgh Postnatal Depression Scale (MDCalc) — standard perinatal depression screen, valid in pregnancy and ≤1 yr postpartum; Cox 1987 Br J Psychiatry.

Suicide risk

• Columbia-Suicide Severity Rating Scale (C-SSRS) — full kit — Columbia/NIMH standard for suicide risk stratification; separate versions for adults, peds, and primary care.
• C-SSRS Screener (MDCalc) — quick 6-question version for triage.
• Ask Suicide-Screening Questions (ASQ, NIMH) — 4-question NIMH-validated peds/adolescent screen with full toolkit for ED, inpatient, outpatient settings.
• SAFE-T (Suicide Assessment Five-step Evaluation and Triage) — SAMHSA pocket card for clinical assessment after a positive screen.
• 988 Suicide & Crisis Lifeline — national crisis line; 24/7.

ADHD

• Vanderbilt ADHD Parent Assessment Scale (NICHQ, PDF) — parent + teacher forms; the AAP CPG–recommended diagnostic instrument.
• Vanderbilt ADHD Diagnostic Rating Scale (MDCalc) — online scoring of the same instrument.
• Adult ADHD Self-Report Scale (ASRS) v1.1 — WHO-developed 18-item adult screen.

Autism / developmental

• M-CHAT-R/F + Follow-Up Interview — Modified Checklist for Autism in Toddlers, Revised; Bright Futures-mandated 18- and 24-month screen. Free with sign-in.
• Ages & Stages Questionnaires (ASQ-3 + ASQ:SE-2) — developmental + social-emotional screens; standard at 9-, 18-, 30-month visits per AAP. Subscription for forms.
• PEDS (Parents’ Evaluation of Developmental Status) — alternative AAP-recognized developmental surveillance instrument.
• AAP Developmental Surveillance & Screening CPG (2020) — operational definition of surveillance + screening cadence; Lipkin et al.

Eating disorders

• SCOFF Questionnaire (MDCalc) — 5-question screen for anorexia/bulimia; Morgan 1999 BMJ. Score ≥2 prompts full workup.
• Eating Disorder Screen for Primary Care (ESP) — NEDA-hosted; alternative 5-question primary-care instrument.

Alcohol & substance use

• AUDIT-C (MDCalc) — 3-question WHO-derived alcohol screen; positive prompts full AUDIT.
• Full AUDIT (10-item, WHO PDF) — full Alcohol Use Disorders Identification Test from WHO.
• CAGE Questions (MDCalc) — classic 4-question alcohol screen; less sensitive than AUDIT-C.
• CRAFFT Screening (adolescent substance use) — Boston Children’s-developed adolescent substance use screen; widely used in Bright Futures visits.
• DAST-10 (Drug Abuse Screening Test, MDCalc) — 10-question non-alcohol substance use screen.
• TAPS Tool (Tobacco, Alcohol, Prescription, Substance use) — NIDA-developed two-stage adult primary-care screen.

Intimate partner violence & social drivers

• HITS (Hurt, Insult, Threaten, Scream) — 4-item IPV screen validated for primary care; AAFP-hosted PDF.
• PRAPARE Tool — NACHC standardized social determinants of health screen.
• AAFP Social Needs Screening Tool — social drivers screening framework for primary care.

Adverse Childhood Experiences

• ACE Questionnaire (CDC overview) — Felitti 1998 Am J Prev Med; foundational trauma-informed screen.
• PEARLS — Pediatric ACEs and Related Life-events Screener — California ACEs Aware-endorsed peds adaptation.

Sleep

• BEARS Sleep Screening Tool — Owens 5-domain peds sleep screen (Bedtime, Excessive daytime sleepiness, Awakenings, Regularity, Snoring).
• Pediatric Sleep Questionnaire (PSQ) — Chervin OSA screen.
• STOP-BANG (Adult OSA, MDCalc) — 8-item adult OSA risk score; Chung 2008 Anesthesiology.
• Epworth Sleepiness Scale (MDCalc) — 8-item daytime sleepiness instrument.

Frailty & geriatric

• Mini-Cog (MDCalc) — rapid cognitive screen; 3-word recall + clock draw.
• MoCA (Montreal Cognitive Assessment) — more sensitive than MMSE for MCI; certification now required for the official version.