Appendix C1.
Parent Screening Questionnaire
Parent Screening Questionnaire
A Safe Environment for Every Kid (SEEK)
Dear parent or caregiver: Being a parent is not easy. We want to help families have a safe
environment for kids. We are asking everyone these questions. Please answer the questions
about your child being seen today for a check-up. They are about issues that affect many
families. If there’s a problem, we’ll try to help.
Today’s Date: / / 200
Child’s Date of Birth: / /
Sex of Child: □ Male □ Female
PLEASE CHECK
□ Yes □ No Do you need the telephone number for Poison Control?
□ Yes □ No Do you need a smoke alarm for your home?
□ Yes □ No Does anyone smoke tobacco at home?
□ Yes □ No Is there a gun in your home?
□ Yes □ No In the last year, did you worry that your food would run out before you
got money or food stamps to buy more?
□ Yes □ No Do you worry that your child may have been physically abused?
□ Yes □ No Do you worry that your child may have been sexually abused?
□ Yes □ No Lately, do you often feel down, depressed, or hopeless?
□ Yes □ No Do you often feel lonely?
□ Yes □ No During the past month, have you felt little interest or pleasure in the
things you used to enjoy?
□ Yes □ No Do you often feel your child is difficult to take care of?
□ Yes □ No Do you wish you had more help with your child?
□ Yes □ No Do you feel so stressed you can’t take another day?
□ Yes □ No Do you sometimes find you need to hit/spank your child?
□ Yes □ No In the past year, have you or your partner had a problem with drugs or alcohol?
□ Yes □ No In the past year, have you or your partner felt the need to cut back on
alcohol?
□ Yes □ No Have you ever been in a relationship in which you were physically hurt
or threatened by a partner?
□ Yes □ No In the past year, have you been afraid of a partner?
□ Yes □ No In the past year have you thought of getting a court order for
protection?
□ Yes □ No Are there any problems you’d like help with today?
Please give this form to the doctor or nurse you’re seeing today. Thank you.
Child Abuse and Neglect Prevention 99 Oregon Evidence-based Practice Center
