Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female HiddenEmail 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 how things have been for you over the last six months.I try to be nice to other people. I care about their feelings.* Not True Somewhat True Certainly True I am restless, I cannot stay still for long* Not True Somewhat True Certainly True I get a lot of headaches, stomach-aches or sickness* Not True Somewhat True Certainly True I usually share with others, for example CDs, games, food* Not True Somewhat True Certainly True I get very angry and often lose my temper* Not True Somewhat True Certainly True I would rather be alone than with people of my age* Not True Somewhat True Certainly True I usually do as I am told* Not True Somewhat True Certainly True I worry a lot* Not True Somewhat True Certainly True I am helpful if someone is hurt, upset, or feeling ill* Not True Somewhat True Certainly True I am constantly fidgeting or squirming* Not True Somewhat True Certainly True I have one good friend or more* Not True Somewhat True Certainly True I fight a lot. I can make other people do what I want* Not True Somewhat True Certainly True I am often unhappy, depressed, or tearful* Not True Somewhat True Certainly True Other people my age generally like me* Not True Somewhat True Certainly True I am easily distracted, I find it difficult to concentrate* Not True Somewhat True Certainly True I am nervous in new situations. I easily lose confidence* Not True Somewhat True Certainly True I am kind to younger children* Not True Somewhat True Certainly True I am often accused of lying or cheating* Not True Somewhat True Certainly True Other children or young people pick on me or bully me* Not True Somewhat True Certainly True I often offer to help others (parents, teachers, children)* Not True Somewhat True Certainly True I think before I do things* Not True Somewhat True Certainly True I take things that are not mine from home, school, or elsewhere* Not True Somewhat True Certainly True I get along better with adults than with people my own age* Not True Somewhat True Certainly True I have many fears, I am easily scared* Not True Somewhat True Certainly True I finish the work I'm doing. My attention is good* Not True Somewhat True Certainly True Do you have any other comments or concerns?Overall, do you think that you have difficulties in any 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 you?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your everyday home life?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your everyday friendships?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your everyday classroom learning?* Not at all Only a little A medium amount A great deal Do the difficulties interfere with your everyday leisure activities?* Not at all Only a little A medium amount A great deal Do the difficulties make it harder for those around you (family, friends, teachers, etc.)?* Not at all Only a little A medium amount A great deal
