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Pediatric Symptoms Checklist - Parent Report Ages 2-18

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Steps

1. Step One This section is complete This section is incomplete
2. Symptom Check List (Page 1 of 4) This section is complete This section is incomplete
3. Symptom Check List (Page 2 of 4) This section is complete This section is incomplete
4. Symptom Check List (Page 3 of 4) This section is complete This section is incomplete
5. Symptom Check List (Page 4 of 4) This section is complete This section is incomplete

Step One

Child's Name*
Child's Date of Birth*
Child's Date of Birth
Today's Date*
Today's Date
School
Grade
Person Completing Form Name*
Relationship*
Person Completing Form Address*
City*
State*
Zip Code*
Phone Number*
Continue

Symptom Check List (Page 1 of 4)

Complains of aches and pains*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Spends more time alone*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Tires easily, has little energy*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Fidgety, unable to sit still*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Has trouble with teacher*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Less interested in school*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Acts as if driven by a motor*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Daydreams too much*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Distracted easily*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Is afraid of new situations*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Continue |Go Back

Symptom Check List (Page 2 of 4)

Feels sad, unhappy*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Is irritable, angry*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Feels hopeless*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Has trouble concentrating*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Less interested in friends*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Fights with other children*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Absent from school*
1. Never (0)
1. Sometimes (1)
1. Often (2)
School grades dropping*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Is down on him or herself*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Visits the doctor with doctor finding nothing wrong*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Continue |Go Back

Symptom Check List (Page 3 of 4)

Has trouble sleeping*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Worries a lot*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Wants to be with you more than before*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Feels he or she is bad*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Takes unnecessary risks*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Gets hurt frequently*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Seems to be having less fun*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Acts younger than children his or her age*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Does not listen to rules*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Does not show feelings*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Continue |Go Back

Symptom Check List (Page 4 of 4)

Does not understand other people's feelings*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Teases others*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Blames others for his or her troubles*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Takes things that do not belong to him or her*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Refuses to share*
1. Never (0)
1. Sometimes (1)
1. Often (2)
Does your child have any emotional or behavioral problems for which she/he needs help?*
1. No
1. Yes
Are there any services that you would like your child to receive for these problems?*
1. No
1. Yes
If yes, what type of services?

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