Pediatric Symptom Checklist Youth Report

Please mark the answer for each question that best describes you.

Complain of aches or pains

Spend more time alone

Tires easily, little energy

Fidgety, unable to sit still

Have trouble with teacher

Less interested in school

Act as if driven by motor

Daydream too much

Distract easily

Are afraid of new situations

Feel sad, unhappy

Are irritable, angry

Feel hopeless

Have trouble concentrating

Less interested in friends

Fight with other children

Absent from school

School grades dropping

Down on yourself

Visit doctor with doctor finding nothing wrong

Have trouble sleeping

Worry a lot

Want to be with parent more than before

Feel that you are bad

Take unnecessary risks

Get hurt frequently

Seem to be having less fun

Act younger than children your age

Do not listen to rules

Do not show feelings

Do not understand other people's feelings

Tease others

Blame others for your troubles

Take things that do not belong to you

Refuse to share


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