Pediatric Symptom Checklist

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Patient *

MRN *

Client Declined

Please mark the option below that best fits your child.

Fidgety, unable to sit still

0 points

Never

1 point

Sometimes

2 points

Often

Feels sad, unhappy

0 points

Never

1 point

Sometimes

2 points

Often

Daydreams too much

0 points

Never

1 point

Sometimes

2 points

Often

Refuses to share

0 points

Never

1 point

Sometimes

2 points

Often

Does not understand other people's feelings

0 points

Never

1 point

Sometimes

2 points

Often

Feels hopeless

0 points

Never

1 point

Sometimes

2 points

Often

Has trouble concentrating

0 points

Never

1 point

Sometimes

2 points

Often

Fights with other children

0 points

Never

1 point

Sometimes

2 points

Often

Is down on him or herself

0 points

Never

1 point

Sometimes

2 points

Often

Blames others for his or her troubles

0 points

Never

10a

1 point

Sometimes

10b

2 points

Often

Seems to be having less fun

0 points

Never

11a

1 point

Sometimes

11b

2 points

Often

Does not listen to rules

0 points

Never

12a

1 point

Sometimes

12b

2 points

Often

Acts as if driven by a motor

0 points

Never

13a

1 point

Sometimes

13b

2 points

Often

Teases others

0 points

Never

14a

1 point

Sometimes

14b

2 points

Often

Worries a lot

0 points

Never

15a

1 point

Sometimes

15b

2 points

Often

Takes things that do not belong to him or her

0 points

Never

16a

1 point

Sometimes

16b

2 points

Often

Distracted easily

0 points

Never

17a

1 point

Sometimes

17b

2 points

Often

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