Below is a list of items that describe children. For each item that describes the child now or within the past 2 months, please circle the 2 if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the item is not true of the child, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to the child.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 1. Aches or pains (without medical cause; do not include stomach or headaches)
0 1 2 2. Acts too young for age
0 1 2 3. Afraid to try new things
0 1 2 4. Avoids looking others in the eye
0 1 2 5. Can’t concentrate, can’t pay attention for long
0 1 2 6. Can’t sit still, restless, or hyperactive
0 1 2 7. Can’t stand having things out of place
0 1 2 8. Can’t stand waiting; wants everything now
0 1 2 9. Chews on things that aren’t edible
0 1 2 10. Clings to adults or too dependent
0 1 2 11. Constantly seeks help
0 1 2 12. Constipated, doesn’t move bowels (when not sick)
0 1 2 13. Cries a lot
0 1 2 14. Cruel to animals
0 1 2 15. Defiant
0 1 2 16. Demands must be met immediately
0 1 2 17. Destroys his/her own things
0 1 2 18. Destroys things belonging to his/her family
or other children
0 1 2 19. Diarrhea or loose bowels (when not sick)
0 1 2 20. Disobedient
0 1 2 21. Disturbed by any change in routine
0 1 2 22. Doesn’t want to sleep alone
0 1 2 23. Doesn’t answer when people talk to him/her
0 1 2 24. Doesn’t eat well (describe): ________________
______________________________________
0 1 2 25. Doesn’t get along with other children
0 1 2 26. Doesn’t know how to have fun; acts like a
little adult
0 1 2 27. Doesn’t seem to feel guilty after misbehaving
0 1 2 28. Doesn’t want to go out of home
0 1 2 29. Easily frustrated
0 1 2 30. Easily jealous
0 1 2 31. Eats or drinks things that are not food—don’t
include sweets (describe): _________________
______________________________________
0 1 2 32. Fears certain animals, situations, or places
(describe): _____________________________
______________________________________
0 1 2 33. Feelings are easily hurt
0 1 2 34. Gets hurt a lot, accident-prone
0 1 2 35. Gets in many fights
0 1 2 36. Gets into everything
0 1 2 37. Gets too upset when separated from parents
0 1 2 38. Has trouble getting to sleep
0 1 2 39. Headaches (without medical cause)
0 1 2 40. Hits others
0 1 2 41. Holds his/her breath
0 1 2 42. Hurts animals or people without meaning to
0 1 2 43. Looks unhappy without good reason
0 1 2 44. Angry moods
0 1 2 45. Nausea, feels sick (without medical cause)
0 1 2 46. Nervous movements or twitching
(describe): _____________________________
______________________________________
0 1 2 47. Nervous, highstrung, or tense
0 1 2 48. Nightmares
0 1 2 49. Overeating
0 1 2 50. Overtired
0 1 2 51. Shows panic for no good reason
0 1 2 52. Painful bowel movements (without medical
cause)
0 1 2 53. Physically attacks people
0 1 2 54. Picks nose, skin, or other parts of body
(describe): _____________________________Sample Does the child have any illness or disability (either physical or mental)? No Yes—Please describe:
Please print your answers. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True
PAGE 2
0 1 2 55. Plays with own sex parts too much
0 1 2 56. Poorly coordinated or clumsy
0 1 2 57. Problems with eyes (without medical cause)
(describe): ___________________________
___________________________________
0 1 2 58. Punishment doesn’t change his/her behavior
0 1 2 59. Quickly shifts from one activity to another
0 1 2 60. Rashes or other skin problems (without
medical cause)
0 1 2 61. Refuses to eat
0 1 2 62. Refuses to play active games
0 1 2 63. Repeatedly rocks head or body
0 1 2 64. Resists going to bed at night
0 1 2 65. Resists toilet training (describe): __________
___________________________________
0 1 2 66. Screams a lot
0 1 2 67. Seems unresponsive to affection
0 1 2 68. Self-conscious or easily embarrassed
0 1 2 69. Selfish or won’t share
0 1 2 70. Shows little affection toward people
0 1 2 71. Shows little interest in things around him/her
0 1 2 72. Shows too little fear of getting hurt
0 1 2 73. Too shy or timid
0 1 2 74. Sleeps less than most kids during day
and/or night (describe): _________________
___________________________________
0 1 2 75. Smears or plays with bowel movements
0 1 2 76. Speech problem (describe): _____________
___________________________________
0 1 2 77. Stares into space or seems preoccupied
0 1 2 78. Stomachaches or cramps (without medical
cause)
0 1 2 79. Rapid shifts between sadness and
excitement
0 1 2 80. Strange behavior (describe): ____________
___________________________________
0 1 2 81. Stubborn, sullen, or irritable
0 1 2 82. Sudden changes in mood or feelings
0 1 2 83. Sulks a lot
0 1 2 84. Talks or cries out in sleep
0 1 2 85. Temper tantrums or hot temper
0 1 2 86. Too concerned with neatness or cleanliness
0 1 2 87. Too fearful or anxious
0 1 2 88. Uncooperative
0 1 2 89. Underactive, slow moving, or lacks energy
0 1 2 90. Unhappy, sad, or depressed
0 1 2 91. Unusually loud
0 1 2 92. Upset by new people or situations
(describe): __________________________
___________________________________
0 1 2 93. Vomiting, throwing up (without medical cause)
0 1 2 94. Wakes up often at night
0 1 2 95. Wanders away
0 1 2 96. Wants a lot of attention
0 1 2 97. Whining
0 1 2 98. Withdrawn, doesn’t get involved with others
0 1 2 99. Worries
0 1 2 100. Please write in any problems the child has
that were not listed above.
0 1 2 _____________________________________
0 1 2 _____________________________________
0 1 2 _____________________________________
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