Pediatric Symptom Checklist-17
Caregiver completing this form
First Name
Last Name
Date
Please select a month
January
February
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April
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December
Month
Please select a day
1
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Day
Please select a year
2030
2029
2028
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2023
Year
Name of child
First Name
Last Name
Rows
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
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