Pediatric Symptom Checklist -- Youth Report(Y-PSC)
;Please mark under the heading that best fits you:
1. Complains of aches or pains
Never
Sometimes
Often
2. Spends more time alone
Never
Sometimes
Often
3. Tires easily, little energy
Never
Sometimes
Often
4. Fidgety, unable to sit still
Never
Sometimes
Often
5. Has trouble with teacher
Never
Sometimes
Often
6. Less interested in school
Never
Sometimes
Often
7. Acts as if driven by motor
Never
Sometimes
Often
8. Daydreams too much
Never
Sometimes
Often
9. Distracts easily
Never
Sometimes
Often
10. Is afraid of new situations
Never
Sometimes
Often
11. Feels sad, unhappy
Never
Sometimes
Often
12. Is irritable, angry
Never
Sometimes
Often
13. Feels hopeless
Never
Sometimes
Often
14. Has trouble concentrating
Never
Sometimes
Often
15. Less interested in friends
Never
Sometimes
Often
16. Fights with other children
Never
Sometimes
Often
17. Absent from school
Never
Sometimes
Often
18. School grades dropping
Never
Sometimes
Often
19. Down on his/herself
Never
Sometimes
Often
20. Visits doctor with doctor finding nothing wrong
Never
Sometimes
Often
21. Has trouble sleeping
Never
Sometimes
Often
22. Worries a lot
Never
Sometimes
Often
23. Wants to be with parent more than before
Never
Sometimes
Often
24. Feels that he/she is bad
Never
Sometimes
Often
25. Takes unnecessary risks
Never
Sometimes
Often
26. Gets hurt frequently
Never
Sometimes
Often
27. Seems to be having less fun
Never
Sometimes
Often
28. Acts younger than children his/her age
Never
Sometimes
Often
29. Does not listen to rules
Never
Sometimes
Often
30. Does not show feelings
Never
Sometimes
Often
31. Does not understand other people's feelings
Never
Sometimes
Often
32. Teases others
Never
Sometimes
Often
33. Blames others for his/her troubles
Never
Sometimes
Often
34. Takes things that does not belong to him/her
Never
Sometimes
Often
35. Refuses to share
Never
Sometimes
Often
Patient Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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