Name of Person Completing this Form
First Name
Last Name
Date of Completion
 /
Month
 /
Day
Year
Date
Date 1. Do you seem to have trouble paying attention, getting things done, listening or sitting still
NO
YES
Answer A Through R
Rows
Never
Some
Often
Very Often
A. Fail to give close attention to details, make careless mistakes
B. Have difficulty keeping your attention on play or tasks
C. Don't seem to listen, even when spoken to directly
D. Don't follow through. Schoolwork or chores, once started, don't get done
E. Can't seem to get organized with tasks or activities
F. You avoid or try to get out of activities that might require sustained attention
G. Lose things necessary for tasks, school or play (toys, assignments, pencils, tools)
H. Easily distracted by the smallest noise or object in the periphery
I. Forgetful
J. Fidgets with hands or feet, or you seem to squirm in your seat
K. Leave your seat in class, or other places that sitting in one place is expected
L. Run about or climb in places where you know you should not.
M. Can't seem to play or do much of anything quietly
N. Seem to be "on the go"' or "driven by a motor
0. You talk too much
P. Blurt out answers even before the question is completed
Q. Can't seem to wait your turn
R. Interrupt or intrudes in to other people's space
2. Do you seem to have an "attitude" more often than not? Do you seem to be hostile, negative, and contrary most days
NO
YES
Answer A Through I
Rows
Never
Some
Often
Very Often
A. Are negative, hostile, and defiant in behavior
B. Lose temper
C. Argue with adults
D. Actively defy, or refuse to abide by, adults' requests or rules
E. Deliberately annoy people
F. Blame others for your mistakes or "bad" behavior
G. Are touchy or easily annoyed by others
H. Are angry and resentful
I. Are spiteful and unforgiving
3. Do you bully, threaten, intimidate, steal etc.? In other words, do you persistently violate the rights of others or the rules of society
NO
YES
Answers A Through P
Rows
Never
Some
Often
Very Often
A. You have developed a pattern where the basic rights of others or society's rules are violated
B. Bully, threaten, or intimidates others
C. Initiate physical fights
D. Have used a weapon toward someone (bat, brick, broken bottle, knife, gun)
E. Are physically cruel to people
F. Are physically cruel to animals
G. Have stolen by mugging, purse snatching, armed robbery or other means of direct confrontation
H. Have forced someone into sexual activity
I. Have started a fire with the intent of causing serious damage
J. Have destroyed someone's property on purpose (other than by fire setting)
K. Have broken into someone's house, building or car
L. You "Con" or lie to obtain favors, goods or to avoid obligations
M. Have stolen items of value not gum or candy etc without confronting a victim shoplifting, forgery etc
N. Stay out at night, despite being told not to. (Must begin before age 13)
0. Have run away from home for a significant period of time
P. Skip school (Must begin before age 13)
4. Do others say, or do you feel you have problems with your mood? Are you sad or irritable for several days in a row, have less energy, or have become withdrawn or isolated
NO
YES
Answer A Through H
Rows
Never
Some
Often
Very Often
A. Are there periods where your mood seems down OR irritable most of the day nearly every day
B. Have you had a significant decrease in interest or pleasure in things
C. Has there been weight loss (or failure to make expected weight gains) when not dieting
D. Are you sleeping less because you can't fall asleep or stay asleep
E. Do you feel, or have others said that you appear, slowed down OR restless
F. Do you have feelings worthless or feeling excessively "guilty" about something
G. Having a hard time making decisions; can't seem to think or remember
H. Are you thinking of suicide or death
5. Do you have periods where rage or excitability seem to last for hours or days or do you feel the opposite of depressed where you are "high on life," have boundless energy and drive etc.
NO
YES
Answer A through I
Rows
Never
Some
Often
Very Often
A. Are there periods (lasting at least several hours) where your mood is abnormally irritable, elevated or uninhibited
B. During these periods do you feel inflated in your self-esteem or do you feel extra special
C. During these periods do you seem to need much less sleep appears rested after only 3 hours etc
D. During these periods are you much more talkative and does your speech seem "pressured" to get words out
E. During these periods do their thoughts seem to come from "nowhere"; difficult to follow or understand
F. Are you much more distractible during these periods
G. Do you have much more energy to complete tasks, achieve conquests or gain accomplishments
H. Have you been physically aggressive during these specific periods
I. Do you become involved in pleasurable activities that have a high potential for painful consequences
6. Do you have trouble with nervousness or fearfulness in situations where other people usually do not? Do you have fears or worries that seem to cause significant distress
NO
YES
Answer A Through G
Rows
Never
Some
Often
Very Ofte
A. Do you have fears that seem excessive or unreasonable
B. Do these fears come about when you think about or come in contact with a certain object or situation
C. The fears described above involve animals, getting a shot, airplanes, storms or any other specific object or situation
D. Exposure to that object or situation causes you to "freeze", have tantrums or be clingy
E. You avoid the object or situation or you endure it with intense anxiety or distress
F. You recognize that the fear is excessive, extreme or unreasonable
G. The avoidance of (or distress from) the object or situation causes loss of esteem or problems at school or home
Rows
Never
Some
Often
Very Ofte
H. Do you have unusual or uncomfortable thoughts, images or impulses that enter into your mind and cause distress (Note: These are not simply excessive worries about real-life problems)
I. Do you attempt to ignore or suppress the thoughts/images by doing rituals or repeated "magical" acts or thoughts
J. Do you realize that the thoughts/images are a product of your mind
K. Are these worries or thoughts seen as excessive, extreme or unreasonable
M. The acts or images cause marked distress, or are very time consuming/interfere with normal life
Rows
Never
Some
Often
Very Often
N. Is there, or has there been, excessive anxiety about being away from home or significant individuals in your life?
O. When separation is anticipated or occurs, is there excessive and recurrent distress?
P. Do you worry excessively about something bad happening to significant others?
Q. Is there a fear that some event being kidnapped or lost etc may cause separation from significant other
R. Is there a reluctance or refusal to go to school (or elsewhere) because of the fear of separation?
S. Is there excessive fear in being alone (or without significant others) at home or in other settings?
T. Is there reluctance or refusal to go to sleep without being near a significant other, or sleep away from home?
U. Are there nightmares involving themes of separation?
V. Are there physical complaints when separation is anticipated or occurs?
7. Do you pull your own hair, resulting in noticeable hair loss?
YES
NO
8. Do you seem to just worry excessively about many things at once (school performance, the future etc.), rather than just one area, as described above? If so, do you seem to have difficulty controlling the worry. Are you irritable and almost physically affected by the worry (restless, fatigued, tensed muscles, can't sleep etc.)?
YES
NO
9. Do you worry about being in a social or performance situation where you might be studied or examined (eating in public, talking in front of class)? If so, do you have an intense fear that you may embarrass yourself?
YES
NO
10. Do you, or did you, refuse to speak in specific social situations when it would be expected to speak (not due to stuttering or not knowing the language etc.)
YES
NO
11. Do you seem to have a lot of physical complaints (not just to avoid obligations, school, or separation)? If so, are there more than 3 "pain" complaints, 2 "stomach" or gastrointestinal complaints and other physical complaints all occurring together during one time
YES
NO
12. Have you suddenly lost the ability to use an arm or a leg, or to feel, or see without any medical explanation
YES
NO
13. Have you been exposed to a trauma where you were threatened of death or serious injury, or witnessed a similar circumstance? If so, did you respond with fear, helplessness, horror, or disorganized/agitated behavior
NO
YES
Answer A Through F
Rows
Never
Some
Often
Very Often
A. Do you have repeated and intruding memories of the event
B. Are there distressing dreams that appear to relate to the trauma
C. Do the events seem to be relived. There may be "flashbacks" or reenactment of the trauma during everyday life
D. Is there intense distress when exposed to thoughts or objects that symbolize or represent the trauma
E. Do you seem to avoid things that are associated with the trauma
F. Are you more aroused or agitated since the trauma can't sleep, outbursts of anger, startle easy, etc.
14. Do you frequently awaken with bad dreams where you can recall these dreams upon awakening? Do these dreams then involve, usually in great detail, threats to your survival or security? If yes to the 2 statements above, are these dreams frequent and/or intense enough to cause interference with school, social, or other important areas of functioning
YES
NO
15. Do you frequently awaken at night with a panicky scream where you may be sweating, breathing fast and appearing frightened? Or, do you sleepwalk so frequently as to cause distress at home or with daytime activities? If so, do others then tell you that you appeared unresponsive to them and, later, do you not remember even having the "bad dream?
YES
NO
16. Have you ever expressed a real and persistent interest in being the opposite sex? If so, did it get to the point where you consistently dressed as the opposite sex, took on the "role" of the opposite sex and express discomfort with being your own sex
YES
NO
17. Do you suspect (or has it been documented) that your reading, mathematics or writing skills are substantially low for your age or level
YES
NO
18. Have you or has anyone noted persistent problems with coordination or clumsiness?
YES
NO
19. Have you or has anyone noticed problems with you having a limited vocabulary, making frequent mistakes in producing sentences, difficulty understanding words or having trouble with words or grammar that might be below that expected for other people your own age?
YES
NO
20. Do you stutter or have trouble talking?
YES
NO
21. Do you notice any twitches, tics, noises that you make that might be repetitive and recurrent (this may be eye blinking, facial or arm twitches, throat clearing, etc.)
YES
NO
22. Do you have a great deal of concern about your weight? If so, are you over concerned with becoming fat, aging weight or do you overeat and make yourself vomit etc.
NO
YES
Rows
Never
Some
Often
Very Often
A. Do you refuse to maintain body weight at or above a "normal" body weight for your age and height?
B. Is there an intense fear of gaining weight or becoming fat, even though underweight?
C. Do you not see yourself as underweight, or do you deny the seriousness of your low body weight, or place undue
D. In girls, has there been an absence of at least 3 menstrual cycles?
E. Are there recurrent episodes of binge eating and a sense of lack of control over the eating during that episode?
F. Are there recurrent episodes of behavior in an attempt to prevent weight gain such as vomiting, misuse of laxatives, fasting or excessive exercise?
23. Do you see or hear things that others don't hear or see?
YES
NO
24. Do you have unusual beliefs or perceptions that defy logic and your family's beliefs
YES
NO
25. Do you use alcohol, drugs, or inhalants?
YES
NO
Rows
Never
Some
Often
Very Often
A. is the use of these substances causing failure to fulfill obligations at home, work, or school?
B. Is there use in situations where it may be physically hazardous?
C. Are there recurrent substance related legal problems?
D. Do you use despite it causing social or interpersonal problems or conflicts?
E. Do you have withdrawal sensations when substances are decreased or stopped, or substances are taken to avoid withdrawal?
F. have there been desires or unsuccessful attempts to cut down or control use?
G. Do you spend time and activities necessary to obtain, use, or recover from the ill effects of the substance?
H. Important social, occupational, or recreational activities are given up or reduced because of the substance use.
I. The substance is used despite knowledge of physical or psychological problems caused or made worse by the substance.
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