Lifted Logic Web Design in Kansas City
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Phone
620.343.2211
Toll Free
800.279.3645
Fax
620.342.1021
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Pediatric Symptom Checklist
Please answer each question to the best of your ability.
Start Free Assessment
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 mark under the heading that best fits your child.
What age group does your child belong to?
*
3-5
6-17
Complains of aches/pains
*
Never
Sometimes
Often
Spends more time alone
*
Never
Sometimes
Often
Tires easily, has little energy
*
Never
Sometimes
Often
Fidgety, unable to sit still
*
Never
Sometimes
Often
Has trouble with a teacher
*
Never
Sometimes
Often
Less interested in school
*
Never
Sometimes
Often
Acts as if driven by a motor
*
Never
Sometimes
Often
Daydreams too much
*
Never
Sometimes
Often
Distracted easily
*
Never
Sometimes
Often
Is afraid of new situations
*
Never
Sometimes
Often
Feels sad, unhappy
*
Never
Sometimes
Often
Is irritable, angry
*
Never
Sometimes
Often
Feels hopeless
*
Never
Sometimes
Often
Has trouble concentrating
*
Never
Sometimes
Often
Less interest in friends
*
Never
Sometimes
Often
Fights with others
*
Never
Sometimes
Often
Absent from school
*
Never
Sometimes
Often
School grades dropping
*
Never
Sometimes
Often
Is down on him or herself
*
Never
Sometimes
Often
Visits doctor with doctor finding nothing wrong
*
Never
Sometimes
Often
Has trouble sleeping
*
Never
Sometimes
Often
Worries a lot
*
Never
Sometimes
Often
Wants to be with you more than before
*
Never
Sometimes
Often
Feels he or she is bad
*
Never
Sometimes
Often
Takes unnecessary risks
*
Never
Sometimes
Often
Gets hurt frequently
*
Never
Sometimes
Often
Seems to be having less fun
*
Never
Sometimes
Often
Acts younger than children his or her age
*
Never
Sometimes
Often
Does not listen to rules
*
Never
Sometimes
Often
Does not show feelings
*
Never
Sometimes
Often
Does not understand other peoples feelings
*
Never
Sometimes
Often
Teases others
*
Never
Sometimes
Often
Blames others for his or her troubles
*
Never
Sometimes
Often
Takes things that do not belong to him or her
*
Never
Sometimes
Often
Refuses to share
*
Never
Sometimes
Often
