CA II CommunityFamily Care Toolkit · v1.0 · 10 September 2026
Psychological and Behavioral Form
Not a diagnostic tool. Gives a professional an organized picture.
Experience with medical procedures
Needle fearHospital fearAnticipatory anxietyReturns to baseline quicklyAdaptation over timePrevious physical restraint during procedures
What helps?
Parent presenceEmotional supportEncouragementDistractionHugs/comfortFamiliar personOther
Social / independence
Scale: independent · needs encouragement · needs familiar person · refuses · varies by day
| Domain | Note |
|---|---|
| New places | |
| New people | |
| Separation from parents | |
| Sleeping independently | |
| Needing sibling/familiar person before activity | |
| Fear of unknown | |
| Dressing independence |
Following instructions
Understands instructionExecutes directlyNeeds encouragementExpects rewardRefuses despite understandingVaries by day
Has a reward become part of the routine?
Mainly medical tasksExtended to daily tasksParent fatigue
Emotional notes
Social fearExcessive attachmentUnexplained irritabilityWorry/preoccupationEmotional sensitivityRapid upsetVariable performanceFear after fracturesFear of movement
Do not label a cause. Possible contributors may include medical experience, repeated procedures, environment, developmental factors, family dynamics, or other causes requiring professional assessment.
Educational and organizational only. Does not diagnose, set doses, or replace a clinician. What you notice at home is not the same as what is in the medical record, and not the same as what the doctor decides.