Pediatric Symptom Checklist-17
Caregiver completing this form
First Name
Last Name
Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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31
Day
2022
2021
2020
2019
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2015
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2012
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Name of child
First Name
Last Name
Never
Sometimes
Often
Please mark under the heading that best fits your child
1. Fidgety, unable to sit still
2. Feels sad or unhappy
3. Daydreams when should be on task
4. Has difficulty cooperating and following rules
5. Struggles to understand other's perspectives
6. Feels hopeless
7. Has trouble concentrating
8. Argues with other cildren or adults
9. Has low self-esteem and puts self down
10. Blames others for his or her troubles
11. Seems to be having less fun than others
12. Misses instructions and doesn't follow through
13. Acts as if driven by a motor
14. Teases others, sometimes in fun but also not
15. Worries a lot
16. Takes things that do not belong to him or her
17. Distracted easily by internal or external stimuli
Submit
Should be Empty: