SAMPLE PROBLEM CHECKLIST
CHILD'S NAME: __________ __________ __________
First Middle Last
CHILD'S GENDER: _____Boy _____ Girl
CHILD'S AGE: _____(Years) ______(Months)
CHILD'S BIRTH DATE: _____ (Month) _____ (Day) _____(Year)
TODAY'S DATE: _____(Month) _____(Day) _____(Year)
Below is a list of items that describes children. For each item that describes th child now or within __________ (days, weeks, or months) please circle the 2, if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the item is not true of the child, circle 0. Please answer all th items as well as you can, even if some do not seem to apply to the child.
0 = not true 1 = somewhat or sometimes true 2 = very true or often true
0 1 2 1.Acts too young for his/her age
0 1 2 2. Drinks alcohol without parents’ approval
0 1 2 3. Fails to finish things he/she starts
0 1 2 4.There is very little he/she enjoys
0 1 2 5. Bowel movements outside toilet
0 1 2 6. Acts too young for age
0 1 2 7. Afraid to try new things
0 1 2 8. Avoids looking others in the eye
0 1 2 9. Can’t concentrate, can’t pay attention for long
0 1 2 10. Can’t sit still, restless, or hyperactive
0 1 2 11. Can’t stand having things out of place
0 1 2 12. Can’t stand waiting; wants everything now
0 1 2 13.Chews on things that aren’t edible
0 1 2 14. Clings to adults or too dependent
0 1 2 15. Defiant
0 1 2 16. Demands must be met immediately
0 1 2 17. Destroys his/her own things
0 1 2 18. Destroys property belonging to others
0 1 2 19. Daydreams or gets lost in his/her thoughts
0 1 2 20. Disobedient
0 1 2 21. Disturbed by any change in routine
0 1 2 22. Cruelty, bullying, or meanness to others
0 1 2 23. Doesn’t answer when people talk to him/her
0 1 2 24. Difficulty following directions
0 1 2 25. Doesn’t get along with other children
0 1 2 26. Doesn’t know how to have fun; acts like a little adult
0 1 2 27. Doesn’t seem to feel guilty after misbehaving
0 1 2 28. Disturbs other children
0 1 2 29. Easily frustrated
0 1 2 30. Easily jealous
0 1 2 31. Feelings are easily hurt
0 1 2 32. Gets hurt a lot, accident-prone
0 1 2 33. Gets in many fights
0 1 2 34. Gets into everything
0 1 2 35. Gets too upset when separated from parents
0 1 2 36. Explosive and unpredictable behavior
0 1 2 37. Headaches (without medical cause)
0 1 2 38. Hits others
0 1 2 39. Holds his/her breath
0 1 2 40. Hurts animals or people without meaning to
0 1 2 41. Looks unhappy without good reason
0 1 2 42. Angry moods
0 1 2 43. Nausea, feels sick (without medical cause)
0 1 2 44. Nervous movements or twitching (describe): ______________________________________
______________________________________
0 1 2 45. Nervous, highstrung, or tense
0 1 2 46. Fails to carry out assigned tasks
0 1 2 47. Fears daycare or school
0 1 2 48. Overtired
0 1 2 49. Fidgets
0 1 2 50. Gets teased by other children
0 1 2 51. Physically attacks people
0 1 2 52. Picks nose, skin, or other parts of body (describe): _____________________________
______________________________________
0 1 2 53. Plays with own sex parts too much
0 1 2 54. Poorly coordinated or clumsy
0 1 2 55. Problems with eyes without medical cause (describe): ___________________________
_____________________________________
0 1 2 56. Punishment doesn’t change his/her behavior
0 1 2 57. Quickly shifts from one activity to another
0 1 2 58. Rashes or other skin problems (without medical cause)
0 1 2 59. Refuses to eat
0 1 2 60. Refuses to play active games
0 1 2 61. Repeatedly rocks head or body
0 1 2 62. Inattentive, easily distracted
0 1 2 63. Lying or cheating
0 1 2 64. Screams a lot
0 1 2 65. Seems unresponsive to affection
0 1 2 66. Self-conscious or easily embarrassed
0 1 2 67. Selfish or won’t share
0 1 2 68. Shows little affection toward people
0 1 2 71. Shows little interest in things around him/her
0 1 2 72. Shows too little fear of getting hurt
Please be sure you have answered all items.
Underline any you are concerned about.
_________________________________________________________________________
Does the child have any illness or disability (either physical or mental)? ___No ___Yes-Please Describe
______________________________________________________________________________________________
What concerns you most about the child?
_________________________________________________________________________
Please describe the best things about the child:
