Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Name* First Last Child's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Gender* Male Female Parent/Guardian Name* First Last Parent/Guardian Email* Relationship to Child* Mother Father Strengths and Difficulties QuestionnaireFor each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all the items as best as your can even if you are not absolutely certain. Please give your answers on the basis of your child's behavior over the last six months.Considerate of other people's feelings* Not True Somewhat True Certainly True Restless, overactive, cannot stay still for long* Not True Somewhat True Certainly True Often complains of headaches, stomach-aches, or sickness* Not True Somewhat True Certainly True Shares readily with other youth, for example CDs, games, food* Not True Somewhat True Certainly True Often loses temper* Not True Somewhat True Certainly True Would rather be alone than with other youth* Not True Somewhat True Certainly True Generally well behaved, usually does what adults request* Not True Somewhat True Certainly True Many worries or often seems worried* Not True Somewhat True Certainly True Helpful if someone is hurt, upset, or feeling ill* Not True Somewhat True Certainly True Constantly fidgeting or squirming* Not True Somewhat True Certainly True Has at least one good friend* Not True Somewhat True Certainly True Often fights with other youth or bullies them* Not True Somewhat True Certainly True Often unhappy, depressed, or tearful* Not True Somewhat True Certainly True Generally liked by other youth* Not True Somewhat True Certainly True Easily distracted, concentration wanders* Not True Somewhat True Certainly True Nervous in new situations, easily loses confidence* Not True Somewhat True Certainly True Kind to younger children* Not True Somewhat True Certainly True Often lies or cheats* Not True Somewhat True Certainly True Picked on or bullied by other youth* Not True Somewhat True Certainly True Often offers to help others (parents, teachers, other children)* Not True Somewhat True Certainly True Thinks things out before acting* Not True Somewhat True Certainly True Steals from home, school, or elsewhere* Not True Somewhat True Certainly True Gets along better with adults than with other youth* Not True Somewhat True Certainly True Many fears, easily scared* Not True Somewhat True Certainly True Good attention span, see chores or homework through to the end* Not True Somewhat True Certainly True Do you have any other comments or concerns?Overall, do you think that your child has difficulties in one or more of the following areas?:*• emotions • concentration • behavior • being able to get on with other people No Yes - minor difficulties Yes - definite difficulties Yes - severe difficulties How long have these difficulties been present?* Less than a month 1-5 months 6-12 months Over a year Do the difficulties upset or distress your child?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your child's everyday home life?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your child's everyday friendships?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your child's everyday classroom learning?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your child's everyday leisure activities?* Not at all Only a little A medium amount A great deal Do the difficulties put a burden on you or the family as a whole?* Not at all Only a little A medium amount A great deal
