Strengths and Difficulties Questionnaire (S11-17)
For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of your behavior over the last 6 months.
Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
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Not True
Somewhat True
Certainly True
I try to be nice to other people, I care about their feelings.
I am restless, I cannot stay still for long.
I get a lot of headaches, stomach-aches, or sickness
I usually share with others, for example CD's, games, food
I get very angry and often lose my temper.
I would rather be alone than with people of my age.
I usually do as I am told
I worry a lot
I am helpful if someone is hurt, upset, or feeling ill
I am constantly fidgeting or squirming
I have one good friend or more
I fight a lot. I can make other people do what I want
I am often unhappy, depressed, or tearful
Other people my age generally like me
I am easily distracted, I find it difficult to concentrate
I am nervous in new situations. I easily lose confidence
I am kind to younger children
I am often accused of lying or cheating
Other children or young people pick on me or bully me
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Type a question
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Not True
Somewhat True
Certainly True
I often offer to help others (parents, teachers, children)
I think before I do things
I take things that are not mine from home, school, or elsewhere
I get along better with adults that with people my own age
I have many fears, I am easily scared
I finish the work I'm doing. My attention is good
Overall do you think that you have difficulties in any of the following areas: Emotions, concentration, behavior or being able to get along with other people?
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No
Yes- minor difficulties
Yes- definite difficulties
Yes- severe difficulties
How long have these difficulties been present?
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Less than a month
1-5 months
6-12 months
Over a year
Do the difficulties upset or distress you?
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Not at all
Only a little
A medium amount
A great deal
Do the difficulties interfere with you everyday life in the following areas?
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Not at all
Only a little
A medium amount
A great deal
Home Life
Friendships
Classroom Learning
Leisure Activities
Do the difficulties make it harder for those around you (family, friends, teachers, etc.)?
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Not at all
Only a little
A medium amount
A great deal
Do you have any other comments or concerns?
Signature
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Date
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Month
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Day
Year
Date
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