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Pictorial Pediatric Symptom Checklist - 17

__________________________________ _________________ _________________Child’sName DateofBirth Today’sDate

Pleasemarkundertheheadingthatbestfitsyourchild:

Fidgety,unabletositstill

Actsasifdrivenbyamotor

Daydreamstoomuch

Distractedeasily

Feelssad,unhappy

1

2

3

4

5

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

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Feelshopeless

Hastroubleconcentrating

Fightswithotherchildren

Isdownonhimorherself

Worriesalot

6

7

8

9

10

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

Seemstobehavinglessfun

NEVER SOMETIMES OFTEN

11

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Doesnotlistentorules

Doesnotunderstandotherpeople’sfeelings

Teasesothers

Blamesothersforhisorhertroubles

Takesthingsthatdonotbelongtohimorher16

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

NEVER SOMETIMES OFTEN

Refusestoshare

NEVER SOMETIMES OFTEN

17

Forofficeuseonly-----------------------------------------------------------------------Factor1_______

Factor2_______

Factor3______

12

13

14

15

©2005JellinekM(asadaptedwithpermissionbyGardnerWandLeinerM,ShirsatP,andMezaT).Permissionisgrantedtoreproducethispage.