Pediatric Symptom Checklist DOWNLOAD PDF Pediatric Symptom Checklist Child’s Name:Record NumberToday ' s DateFilled out byDate of BirthEmail Address1. Complains of aches/painsNeverSometimesOften2. Spends more time aloneNeverSometimesOften3. Tires easily, has little energyNeverSometimesOften4. Fidgety, unable to sit stillNeverSometimesOften5. Has trouble with a teacherNeverSometimesOften6. Less interested in schoolNeverSometimesOften7. Acts as if driven by a motorNeverSometimesOften8. Daydreams too muchNeverSometimesOften9. Distracted easilyNeverSometimesOften10. Is afraid of new situationsNeverSometimesOften11. Feels sad, unhappyNeverSometimesOften12. Is irritable, angryNeverSometimesOften13. Feels hopelessNeverSometimesOften14. Has trouble concentratingNeverSometimesOften15. Less interest in friendsNeverSometimesOften16. Fights with othersNeverSometimesOften17. Absent from schoolNeverSometimesOften18. School grades droppingNeverSometimesOften19. Is down on him or herselfNeverSometimesOften20. Visits doctor with doctor finding nothing wrongNeverSometimesOften21. Has trouble sleepingNeverSometimesOften22. Worries a lotNeverSometimesOften23. Wants to be with you more than beforeNeverSometimesOften24. Feels he or she is badNeverSometimesOften25. Takes unnecessary risksNeverSometimesOften26. Gets hurt frequentlyNeverSometimesOften27. Seems to be having less funNeverSometimesOften28. Acts younger than children his or her ageNeverSometimesOften29. Does not listen to rulesNeverSometimesOften30. Does not show feelingsNeverSometimesOften31. Does not understand other people's feelingsNeverSometimesOften32. Teases othersNeverSometimesOften33. Blames others for his or her troublesNeverSometimesOften34. Takes things that do not belong to him or herNeverSometimesOften35. Refuses to shareNeverSometimesOftenDoes your child have any emotional or behavioral problems for which she/he needs help?YesNoAre there any services that you would like your child to receive for these problems?YesNoTotal scoreIf yes, what services?Submit form
