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Forms – PSC
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. Complains of aches and pains
*
Always
Sometimes
Never
2. Spends more time alone
*
Always
Sometimes
Never
3. Tires easily, has little energy
*
Always
Sometimes
Never
4. Fidgety, unable to sit still
*
Always
Sometimes
Never
5. Has trouble with teacher
*
Always
Sometimes
Never
6. Less interested in school
*
Always
Sometimes
Never
7. Acts as if driven by a motor
*
Always
Sometimes
Never
8. Daydreams too much
*
Always
Sometimes
Never
9. Distracted easily
*
Always
Sometimes
Never
10. Is afraid of new situations
*
Always
Sometimes
Never
11. Feels sad, unhappy
*
Always
Sometimes
Never
12. Is irritable, angry
*
Always
Sometimes
Never
13. Feels hopeless
*
Always
Sometimes
Never
14. Has trouble concentrating
*
Always
Sometimes
Never
15. Less interested in friends
*
Always
Sometimes
Never
16. Fights with other children
*
Always
Sometimes
Never
17. Absent from school
*
Always
Sometimes
Never
18. School grades dropping
*
Always
Sometimes
Never
19. Is down on him or herself
*
Always
Sometimes
Never
20. Visits the doctor with doctor finding nothing wrong
*
Always
Sometimes
Never
21. Has trouble sleeping
*
Always
Sometimes
Never
22. Worries a lot
*
Always
Sometimes
Never
23. Wants to be with you more than before
*
Always
Sometimes
Never
24. Feels he or she is bad
*
Always
Sometimes
Never
25. Takes unnecessary risks
*
Always
Sometimes
Never
26. Gets hurt frequently
*
Always
Sometimes
Never
27. Seems to be having less fun
*
Always
Sometimes
Never
28. Acts younger than children his or her age
*
Always
Sometimes
Never
29. Does not listen to rules
*
Always
Sometimes
Never
30. Does not show feelings
*
Always
Sometimes
Never
31. Does not understand other people's feelings
*
Always
Sometimes
Never
32. Teases others
*
Always
Sometimes
Never
33. Blames others for his or her troubles
*
Always
Sometimes
Never
34. Takes things that do not belong to him or her
*
Always
Sometimes
Never
35. Refuses to share
*
Always
Sometimes
Never
Total
Calculated – do not edit
