Pediatric Symptom Checklist

Pediatric Symptom Checklist

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Person Completing This Form*

First NameLast Name
Relationship to Patient*
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.*

	Never (0)	Sometimes (1)	Often (2)
1. Complains of aches/pains
2. Spends more time alone
3. Tires easily, has little energy
4. Fidgety, unable to sit still
5. Has trouble with a teacher
6. Less interested in school
7. Acts as if driven by a motor
8. Daydreams too much
9. Distracted easily
10. Is afraid of new situations
11. Feels sad, unhappy
12. Is irritable, angry
13. Feels hopeless
14. Has trouble concentrating
15. Less interest in friends
16. Fights with others
17. Absent from school
18. School grades dropping
19. Is down on him or herself
20. Visits doctor with doctor finding nothing wrong
21. Has trouble sleeping
22. Worries a lot
23. Wants to be with you more than before
24. Feels he or she is bad
25. Takes unnecessary risks
26. Gets hurt frequently
27. Seems to be having less fun
28. Acts younger than children his or her age
29. Does not listen to rules
30. Does not show feelings
31. Does not understand other people's feelings
32. Teases others
33. Blames others for his or her troubles
34. Takes things that do not belong to him or her
35. Refuses to share

Total Score
Does your child have any emotional or behavioral problems for which she/he needs help?*

NoYes
Are there any services that you would like your child to receive for these problems?*

NoYes
What services?*
Should be Empty: