Child Evaluation Form (ages 6-10) • Zumbro Valley Health Center

Date*

Parent/Guardian Name*

First Last

Parent/Guardian Email*

Enter Email Confirm Email

Child's Name*

First Last

Child's Date of Birth*

Child's Gender

Male
Female

Strengths and Difficulties

For 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:

Please list any other symptoms

Child symptoms only
Aches/pains
Anxious/nervous
Ashamed
Body image concerns
Can't enjoy myself
Choking feeling
Cries easily/often
Decreased appetite/weight loss
Depressed/sad
Difficulty breathing
Distressing memories
Disturbing thoughts
Dizziness
Elevated mood
Excessive worry
Feels inferior
Feels unworthy
Feeling paranoid/suspicious
Frequent mood swings
Guilt feelings
Headaches
Hears voices
Heart racing
Heavy feeling
Hopelessness
Increased appetite/weight gain
Irritable/angry
Lack of motivation
Loneliness
Loses temper
Low energy/tired
Low self-esteem
Nightmares
Numbing/tingling
Poor concentration
Poor memory
Racing thoughts
Repetitive actions
Restless/fidgety
Sees images or objects
Self harming behaviors/urges
Sexual issues/concerns
Shaking
Sleep problems
Social discomfort
Tense feelings
Thoughts of wanting to die
Thoughts of wanting to hurt others
Violent behavior
Wound up