DSM 5 - Parent/Guardian Rated

Client's Legal Full Name

Child's age

DoB*

Date

Gender

Instructions (to the parent or guardian of the child): The questions below ask about things that might have bothered your child. For each questions, select the outcome that best describes how much (or how often) your child has been bothered by each problem during the past two (2) weeks.

Complained of stomachaches, headaches or other aches and pains?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said they were worried about their health or about getting sick?

	0	1	2	3	4	5

0 is None, 5 is Severe

Had problems sleeping - that is, trouble falling asleep, staying asleep or waking up too early?

	0	1	2	3	4	5

0 is None, 5 is Severe

Had problems paying attention when they were in class or doing their homework, reading book or playing games?

	0	1	2	3	4	5

0 is None, 5 is Severe

Had less fun doing things than they used to?

	0	1	2	3	4	5

0 is None, 5 is Severe

Seemed sad or depressed for several hours?

	0	1	2	3	4	5

0 is None, 5 is Severe

Seemed more irritated or easily annoyed than usual?

	0	1	2	3	4	5

0 is None, 5 is Severe

Seemed angry or lost their temper?

	0	1	2	3	4	5

0 is None, 5 is Severe

Started lots more projects than usual, or did more risky things?

	0	1	2	3	4	5

0 is None, 5 is Severe

Slept less than usual for them, but still had lots of energy?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said they felt nervous, anxious, or scared?

	0	1	2	3	4	5

0 is None, 5 is Best

Not been able to stop worrying?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said they heard voices - when there was no one there - speaking about them or telling them what to do or saying bad things to them?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said that they had a vision when they was completely awake - that is, saw something or someone that no one else could see?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said that they had thoughts that kept coming into their mind that they would do something bad or that something bad would happen to them or someone else?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said that they felt the need to check on certain things over and over again, like whether a door is locked or whether the stove was turned off?

	0	1	2	3	4	5

0 is None, 5 is Severe

Seemed to worry a lot about things they touched being dirty or having germs or being poisoned?

	0	1	2	3	4	5

0 is None, 5 is Severe

Said that they had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening?

	0	1	2	3	4	5

0 is None, 5 is Severe

Had an alcoholic beverage (beer,wine,liquor, etc)

	0	1	2	3	4	5

0 is None, 5 is Severe

Smoked a cigarette, a cigar, a pipe or used snuff or chewing tobacco?

	0	1	2	3	4	5

0 is None, 5 is Severe

Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?

	0	1	2	3	4	5

0 is None, 5 is Severe

Used any medicine without a doctor's prescription( eg, painkillers (like Vicodin), stimulants (like Ritalin), sedatives or tranquilizers (like sleeping pills, Valium or steroids)

	0	1	2	3	4	5

0 is None, 5 is Severe

In the past two (2) weeks, has he/she talked about wanting to kill themselves or about wanting to commit suicide

YesNoUnsure

Have they ever tried to kill themselves?

YesNoUnsure

Full Name*

First NameLast Name

Relationship with the child

Date

Signature*

DSM 5- Parent/Guardian Rated Level 1