Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name* First Last Parent/Guardian Email* Enter Email Confirm Email Child's Name* First Last Child's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's GenderMaleFemaleStrengths and DifficultiesFor each item, please mark the box Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best as you 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 children, for example toys, treats, pencils Not True Somewhat True Certainly True Often loses temper Not True Somewhat True Certainly True Rather solitary, prefers to play alone 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 others children or bullies them Not True Somewhat True Certainly True Often unhappy, depressed, or tearful Not True Somewhat True Certainly True Generally liked by other children Not True Somewhat True Certainly True Easily distracted, concentration wanders Not True Somewhat True Certainly True Nervous or clingy 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 children 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 children 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, or being able to get on with other people? No Yes - minor difficulties Yes - definite difficulties Yes - severe difficulties Do the difficulties upset or distress your child? 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 Do the difficulties interfere with your child's everyday life in the following areas?Home Life Not at all Only a little A medium amount A great deal Friendships Not at all Only a little A medium amount A great deal Classroom Learning Not at all Only a little A medium amount A great deal Leisure Activities Not at all Only a little A medium amount A great deal Please check the symptoms you are having now:Child symptoms onlyAches/painsAnxious/nervousAshamedBody image concernsCan't enjoy myselfChoking feelingCries easily/oftenDecreased appetite/weight lossDepressed/sadDifficulty breathingDistressing memoriesDisturbing thoughtsDizzinessElevated moodExcessive worryFeels inferiorFeels unworthyFeeling paranoid/suspiciousFrequent mood swingsGuilt feelingsHeadachesHears voicesHeart racingHeavy feelingHopelessnessIncreased appetite/weight gainIrritable/angryLack of motivationLonelinessLoses temperLow energy/tiredLow self-esteemNightmaresNumbing/tinglingPoor concentrationPoor memoryRacing thoughtsRepetitive actionsRestless/fidgetySees images or objectsSelf harming behaviors/urgesSexual issues/concernsShakingSleep problemsSocial discomfortTense feelingsThoughts of wanting to dieThoughts of wanting to hurt othersViolent behaviorWound upPlease list any other symptoms
