Children's Checklist
First Name:
Last Name:
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
COMMON PROBLEMS
No single question is critical. Just answer the best you can. Thank you!
Attention Problems
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Misses important information
Has trouble listening
Makes careless errors
Short attention span
Disorganized/can’t prioritize
Procrastinates
Easily distracted
Difficulty staying on task
Avoids initiating mental effort
Lacks interest in activities
Loses things
Gets bored easily
Daydreams/spaces-out
Low energy/sleepy during the day
Apathetic/unmotivated
Dislikes sustained mental effort
Underachiever
Trouble following directions
Difficulty remembering
Easily frustrated
Acts before thinking/impulsive
Trouble changing focus
Inflexible/avoids change
Doesn’t anticipate consequences of behavior
Frequently repeats thoughts and words
First Name:
Last Name:
Emotion/Behavior
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Disruptive
Hyper, fidgets, squirms, can’t sit still
Tics/repetitive behavior
Difficulty working quietly
Talks excessively/interrupts others
Teases or tricks peers
Impatient/difficulty waiting turn
Risk-taking behavior
Blurts out comments inappropriately
Grouchy, irritable
Immature behavior/silly
Sad or moody
Nervous/jumpy/fearful
Easily upset/tearful
Explosive/angry/lashes out
Loses temper easily
Oppositional/argues
Defies rules
Spiteful/vindictive
Lies, cheats, steals
Deliberately annoys others
Resists authority or discipline
Blames others for difficulty
Frequently in trouble
Aggressive toward peers
Cruel to animals/destroys objects
Poor eye contact
Sensitive to clothing or touch
Lacks empathy
Excessive worry or fearful
First Name:
Last Name:
Other Problems
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Poor reading comprehension
Poor handwriting
Difficulty copying from the board
Difficulty writing notes in class
Slow to process information
Difficulty expressing/getting the right words out
Difficulty with expressive writing
Can’t summarize or explain simply
Auditory processing issues
Difficulty telling left from right
Food sensitivities
Lack of body awareness
Stutters
History of earaches
History of sinus issues
History of stomach complaints
History of seizures
Neurological disorders
Vision problems
Nail biting or nervous habits
Constipation
Poor appetite
Mold exposure
Asthma
Allergies
Poor coordination, clumsy, poor motor skills
Sleep
Rows
None/Very Mild
Mild
Moderate
Severe/Very Severe
Comments
Restless sleep
Bad dreams or nightmares
Teeth grinding
Bed wetting
Sleepwalking
Talking in sleep
Night terrors
Wakes early
Difficulty going into bed
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