Pediatric Symptom Checklist

Please mark under the heading that best describes your child.

Feels sad, unhappy

Never

Sometimes

Often

Feels hopeless

Never

Sometimes

Often

Is down on self

Never

Sometimes

Often

Worries a lot

Never

Sometimes

Often

Seems to be having less fun

Never

Sometimes

Often

Fidgety, unable to sit still

Never

Sometimes

Often

Daydreams too much

Never

Sometimes

Often

Distracted easily

Never

Sometimes

Often

Has trouble concentrating

Never

Sometimes

Often

Acts as if driven by a motor

Never

Sometimes

Often

Fights with other children

Never

Sometimes

Often

Does not listen to rules

Never

Sometimes

Often

Does not understand other people’s feelings

Never

Sometimes

Often

Teases others

Never

Sometimes

Often

Blames others for his/her troubles

Never

Sometimes

Often

Refuses to share

Never

Sometimes

Often

Takes things that do not belong to him/her

Never

Sometimes

Often

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