Tic Disorder
How often does your child experience sudden, brief, repetitive movements or vocalizations?
Never
Rarely
Sometimes
Very frequently
Do these movements or sounds seem to be involuntary or out of your child's control?
Not applicable, no tics
Not at all
Occasionally
Extremely
Can your child suppress these tics temporarily?
Not applicable, no tics
No, never
Sometimes
Yes, frequently
Do the tics appear or worsen with stress or excitement?
Not applicable, no tics
No change
Moderate worsening
Significant worsening
Has your child complained of a premonitory urge (an urge before the tic occurs)?
Not applicable, no tics
Never
Occasionally
Always
Are the tics noticeable to others around your child?
Not applicable, no tics
Not noticeable
Noticeable upon close observation
Very noticeable
Do these tics disrupt your child’s daily activities?
Not applicable, no tics
Not at all
Moderately
Severely
How long have these tics been present?
Not applicable, no tics
Less than 4 weeks
4 weeks to under a year
Over a year
Did the tics start before the age of 18?
Not applicable, no tics
No
Yes
Has your child experienced any improvement in tics with intervention or over time?
Not applicable, no tics
No improvement
Some improvement
Significant improvement
PANS/PANDAS
Did your child suddenly develop OCD or eating restrictions?
No symptoms
No
Developed gradually
Yes, very sudden
Are your child’s symptoms episodic, appearing severely then diminishing?
No symptoms
Not episodic
Somewhat episodic
Highly episodic
Has your child experienced sudden, dramatic mood changes?
No symptoms
No
Mild mood changes
Extreme and sudden changes
Does your child exhibit signs of separation anxiety or become clingy unexpectedly?
No symptoms
Never
Sometimes
Very often
Has your child shown any signs of nighttime bedwetting or urinary frequency?
No symptoms
Not at all
Occasionally
Frequently
Has your child developed motor or vocal tics suddenly?
No symptoms
No
Gradually
Yes, very suddenly
Have you noticed changes in your child’s handwriting or other motor skills?
No symptoms
No changes
Minor changes
Significant changes
Does your child complain of joint pain or have been seen to have involuntary limb movements?
No symptoms
Never
Occasionally
Frequently
Have symptoms worsened following an illness like strep throat?
No symptoms
No worsening
Some worsening
Severe worsening post-illness
Is your child experiencing heightened sensory sensitivities?
No symptoms
Not sensitive
Mildly sensitive
Extremely sensitive
Tourette's Syndrome
Does your child exhibit both multiple motor tics and at least one vocal tic?
No symptoms
No
Only one type (motor or vocal)
Yes, both present
Have these tics been ongoing for more than one year?
No symptoms
Less than a yea
More than a year
Were these symptoms present before the age of 18?
No symptoms
No
Yes
Do the tics occur many times a day (almost every day)?
No symptoms
Rarely
Occasionally
Very frequently
Has your child's social or school life been impacted by these tics?
No symptoms
No impact
Moderate impact
Severe impact
Do stress or excitement seem to increase the frequency or intensity of the tics?
No symptoms
No change
Moderate increase
Significant increase
Can your child suppress these tics voluntarily?
No symptoms
Cannot suppress
With difficulty
Can suppress well
Do the tics improve with distraction or focus on an activity?
No symptoms
No improvement
Some improvement
Great improvement
Is there a family history of tics or Tourette's Syndrome?
No symptoms
No family history
Some relatives
Strong family history
Has your child been treated for tics, and if so, was the treatment effective?
No symptoms
No treatment or ineffective treatment
Moderately effective
Highly effective treatment
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