Pediatric Symptom Checklist Parent Completed Ages 4-5

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.

Complains of aches and pains

Spends more time alone

Tires easily, has little energy

Fidgety, unable to sit still

Has trouble with teacher

Less interested in school

Acts as if driven by a motor

Daydreams too much

Distracted easily

Is afraid of new situations

Feels sad, unhappy

Is irritable, angry

Feels hopeless

Has trouble concentrating

Less interested in friends

Fights with other children

Absent from school

School grades dropping

Is down on him or herself

Visits the doctor with doctor finding nothing wrong

Has trouble sleeping

Worries a lot

Wants to be with you more than before

Feels he or she is bad

Takes unnecessary risks

Gets hurt frequently

Seems to be having less fun

Acts younger than children his or her age

Does not show feelings

Does not understand other people’s feelings

Teases others

Blames others for his or her troubles

Takes things that do not belong to him or her

Refuses to share


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