Pediatric Symptom Checklist (PSC)

DATE:

COMPLETED BY:

NAME:

RECORD #:

DATE OF BIRTH:

Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions or learning, you may help your child get the best care possible by answering these questions. Please indicate which statement best describes your child.

Please mark under the heading that best describes your child:

0 - Never
1 - Sometimes
2 - Often

1. Complains of aches and pains

0 1 2

2. Spends more time alone

0 1 2

3. Tires easily, has little energy

0 1 2

4. Fidgety, unable to sit still

0 1 2

5. Has trouble with teacher

0 1 2

6. Less interested in school

0 1 2

7. Acts as if driven by a motor

0 1 2

8. Daydreams too much

0 1 2

9. Distracted easily

0 1 2

10. Is afraid of new situations

0 1 2

11. Feels sad, unhappy

0 1 2

12. Is irritable, angry

0 1 2

13. Feels hopeless

0 1 2

14. Has trouble concentrating

0 1 2

15. Less interested in friends

0 1 2

16. Fights with other children

0 1 2

17. Absent from school

0 1 2

18. School grades dropping

0 1 2

19. Is down on him or herself

0 1 2

20. Visits the doctor with doctor finding nothing wrong

0 1 2

21. Has trouble sleeping

0 1 2

22 Worries a lot

0 1 2

23. Wants to be with you more than before

0 1 2

24. Feels he or she is bad

0 1 2

25. Takes unnecessary risks

0 1 2

26. Gets hurt frequently

0 1 2

27. Seems to be having less fun

0 1 2

28. Acts younger than children his or her age

0 1 2

29. Does not listen to rules

0 1 2

30. Does not show feelings

0 1 2

31 Does not understand other people's feelings

0 1 2

32. Teases others

0 1 2

33. Blames others for his or her troubles

0 1 2

34. Takes things that do not belong to him or her

0 1 2

35. Refuses to share

0 1 2

Total score:

Does your child have any emotional or behavioral problems for which she/he needs help?-

Yes No

Are there any services that you would like your child to receive for these problems?

Yes No

If yes, what type of services?

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