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Pediatric Symptom Checklist (PSC-17)
Pediatric Symptom Checklist
Child's name
*
First
Last
Child's date of birth
*
MM slash DD slash YYYY
Today's date
*
MM slash DD slash YYYY
Please select the answer that best describes your child:
1. Feels sad, unhappy
*
Often
Sometimes
Never
2. Feels hopeless
*
Often
Sometimes
Never
3. Is down on self
*
Often
Sometimes
Never
4. Worries a lot
*
Often
Sometimes
Never
5. Seems to be having less fun
*
Often
Sometimes
Never
6. Fidgety, unable to sit still
*
Often
Sometimes
Never
7. Daydreams too much
*
Often
Sometimes
Never
8. Distracted easily
*
Often
Sometimes
Never
9. Has trouble concentrating
*
Often
Sometimes
Never
10. Acts as if driven by a motor
*
Often
Sometimes
Never
11. Fights with other children
*
Often
Sometimes
Never
12. Does not listen to rules
*
Often
Sometimes
Never
13. Does not understand other people’s feelings
*
Often
Sometimes
Never
14. Teases others
*
Often
Sometimes
Never
15. Blames others for his/her troubles
*
Often
Sometimes
Never
16. Refuses to share
*
Often
Sometimes
Never
17. Takes things that do not belong to him/her
*
Often
Sometimes
Never
Does your child have any emotional or behavioral problems for which she/he needs help?
*
Yes
No
Total
Calculated – do not edit
