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SYMPTOM SCREENING
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Please enter the name of the person filling out this form
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What is your relationship to the patient (e.g., parent, guardian, teacher)?
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Please read through the instructions
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Is this evaluation based on a time when the child
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1. Does not pay attention to details or makes careless mistakes with, for example, homework
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2. Has difficulty keeping attention to what needs to be done
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3. Does not seems to listen when spoken to directly
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4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
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5. Has difficulty organizing tasks and activities
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6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
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7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
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8. Is easily distracted by noises or other stimuli
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9. Is forgetful in daily activities
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10. Fidgets with hands or feet or squirms in seat
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11. Leaves seat when remaining seated is expected
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12. Runs about or climbs too much when remaining seated is expected
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13. Has difficulty playing or beginning quiet play activities
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14. Is "on the go" or often acts as if "driven by a motor"
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15. Talks too much
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16. Blurts out answers before questions have been completed
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17. Has difficulty waiting his or her turn
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18. Interrupts or intrudes in on others' conversations and/or activities
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19. Argues with adults
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20. Loses temper
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21. Actively defies or refuses to go along with adults' requests or rules
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22. Deliberately annoys people
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23. Blames others for his or her mistakes or misbehaviors
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24. Is touchy or easily annoyed by others
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25. Is angry or resentful
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26. Is spiteful and wants to get even
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27. Bullies, threatens, or intimidates others
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28. Starts physical fights
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29. Lies to get out of trouble or to avoid obligations (i.e., "cons" others)
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30. Is truant from school (skips school) without permission
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31. Is physically cruel to people
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32. Has stolen things that have value
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33. Deliberately destroys others' property
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34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
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35. Is physically cruel to animals
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36. Has deliberately set fires to cause damage
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37. Has broken into someone else's home, business, or car
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38. Has stayed out at night without permission
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39. Has run away from home overnight
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40. Has forced someone into sexual activity
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41. Is fearful, anxious, or worried
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42. Is afraid to try new things for fear of making mistakes
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43. Feels worthless or inferior
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44. Blames self for problems, feels guilty
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45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
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46. Is sad, unhappy, or depressed
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47. Is self-conscious or easily embarrassed
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48. Overall school performance
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49. Reading
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50. Writing
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51. Mathematics
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52. Relationship with parents
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53. Relationship with siblings
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54. Relationship with peers
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55. Participation in organized activities (e.g., teams)
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56. Complains of stomach aches
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57. Pouts and sulks
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58. Appears happy
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59. Unable to make up his/her mind
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60. Cries often
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61. Moves slowly
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62. Complains of headache
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63. Demonstrates slow speech
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64. Spends more time with adults
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65. Talks a lot
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66. Spends time alone in room
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67. Carefree in spirit
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68. Self critical
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69. Finds it difficult to leave parents
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70. Enjoys new situations
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71. Forgetful
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72. Easily frustrated
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73. Tires easily
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74. Gets angry
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75. Hostile to others
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76. Sullen
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77. Bowel problems
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78. Cheerful in nature
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79. Nausea or vomiting
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80. Temper outbursts
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81. Neat appearance
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82. Suicidal thoughts
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83. Eats poorly
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84. Falls asleep well
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85. Refuses to go to school
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86. Leaves school - "hooks"
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87. Moody or irritable
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88. Talks about fear of parents dying
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89. Works on tasks enthusiastically
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90. Sleeps through the night
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91. Awakens in morning earlier than necessary
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92. Needs help from adults
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93. Generally outgoing
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Please read through the instructions
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94. When my child feels frightened, it is hard for him/her to breathe
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95. My child gets headaches when he/she is at school
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96. My child doesn't like to be with people he/she doesn't know well
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97. My child gets scared if he/she sleeps away from home
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98. My child worries about other people liking him/her
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99. When my child gets frightened, he/she feels like passing out
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100. My child is nervous
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101. My child follows me wherever I go
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102. People tell me that my child looks nervous
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103. My child feels nervous with people he/she doesn't know well
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104. My child gets stomachaches at school
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105. When my child gets frightened, he/she feels like he/she is going crazy
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106. My child worries about sleeping alone
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107. My child worries about being as good as other kids
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108. When my child gets frightened, he/she feels like things are not real
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109. My child has nightmares about something bad happening to his/her parents
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110. My child worries about going to school
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111. When my child gets frightened, his/her heart beats fast
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112. My child gets shaky
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113. My child has nightmares about something bad happening to him/her
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114. My child worries about things working out for him/her
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115. When my child gets frightened, he/she sweats a lot
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116. My child is a worrier
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117. My child gets really frightened for no reason at all
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118. My child is afraid to be alone in the house
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119. It is hard for my child to talk with people he/she doesn't know well
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120. When my child gets frightened, he/she feels like he/she is choking
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121. People tell me that my child worries too much
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122. My child doesn't like to be away from his/her family
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123. My child is afraid of having anxiety (or panic) attacks
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124. My child worries that something bad might happen to his/her parents
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125. My child feels shy with people he/she doesn't know well
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126. My child worries about what is going to happen in the future
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127. When my child gets frightened, he/she feels like throwing up
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128. My child worries about how well he/she does things
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129. My child is scared to go to school
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130. My child worries about things that have already happened
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131. When my child gets frightened, he/she feels dizzy
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132. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her
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133. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn't
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134. My child is shy
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Questions 135 & 136
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135. Does your child have thoughts or obsessions about which they can't stop thinking? Obsessions are thoughts, ideas, or pictur
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136. Does your child have compulsions or habits which they can't stop doing? Compulsions are things that your child feels he or
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Questions 137 & 138
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137. Has your child ever experienced any of the following traumatic events: natural disaster (e.g., flood, hurricane, tornado, e
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138. Has your child had any unusual experiences such as: hearing voices, seeing visions, having ideas they later found out were
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139. Are you concerned your child has been drinking alcohol?
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140. Are you concerned your child has been using marijuana, illegal drugs, or prescription medications for non-medical reasons?
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141. Are you concerned about your child's overall level of development?
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142. Are you concerned about your child's development in the areas of speech and language?
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143. Are you concered about your child's learning development in the areas of mathematics, reading, etc.?
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Question 144
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144. Has your child had problems with social interactions (e.g., eye contact, social reciprocity, making and keeping friends); s
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145. Has your child had any problems with enuresis (bed-wetting)?
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146. Has your child had any problems with encopresis (fecal incontinence)?
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