Psychiatric Checklist (Parent/Guardian Version)
Patient Name
Relationship to Child/Adolescent
Parent/guardian Email address
example@example.com
Date of Form Completion
-
Month
-
Day
Year
Date
Date 1. Does your child 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. Fails to give close attention to details, make careless mistakes
B. Has difficulty keeping attention on play or tasks
C. Doesn't seem to listen, even when spoken to directly
D.
Doesn't
follow through. Schoolwork or chores, once started, don't get done
E. Can't seem to get organized with tasks or activities
F. Avoids or tries to get out of activities that might require sustained attention
G. Loses 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 seems to squirm in their seat
K. Leaves the seat in class, or other places that sitting in one place is expected
L. Runs about or climbs in places where they know they should not.
M. Can't seem to play or do much of anything quietly
N. Seems to be "on the go"' or "driven by a motor
0. Talks too much
P. Blurts out answers even before the question is completed
Q. Can't seem to wait their turn
R. Interrupts or intrudes in to other people's space
2. Does your child seem to have an "attitude" more often than not? Do he or she seem to be hostile, negative, and contrary most days?
NO
YES
Answer A Through I
Rows
Never
Some
Often
Very Often
A. Is 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 annoys people
F. Blames others for their mistakes or "bad" behavior
G. Is touchy or easily annoyed by others
H. Is angry and resentful
I. Is spiteful and unforgiving
3. Does your child bully, threaten, intimidate, steal etc.? In other words, do they persistently violate the rights of others or the rules of society?
NO
YES
Answers A Through P
Rows
Never
Some
Often
Very Often
A. Has developed a pattern where the basic rights of others or society's rules are violated
B. Bullies, threatens, or intimidates others
C. Initiates physical fights
D. Has used a weapon toward someone (bat, brick, broken bottle, knife, gun)
E. Is physically cruel to people
F. Is physically cruel to animals
G. Has stolen by mugging, purse snatching, armed robbery or other means of direct confrontation
H. Has forced someone into sexual activity
I. Has started a fire with the intent of causing serious damage
J. Has destroyed someone's property on purpose (other than by fire setting)
K. Has broken into someone's house, building or car
L. "Cons" or lie to obtain favors, goods or to avoid obligations
M. Has stolen items of value not gum or candy etc without confronting a victim shoplifting, forgery etc
N. Stays out at night, despite being told not to. (Must begin before age 13)
0. Has run away from home for a significant period of time
P. Skips school (Must begin before age 13)
4. Does your child appear to have problems with their mood? Are they 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 their mood seems down OR irritable most of the day nearly every day?
B. Do they appear to have 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 they sleeping less because they can't fall asleep or stay asleep?
E. Do they appear slowed down OR restless?
F. Do they express feelings worthless or feeling excessively "guilty" about things?
G. Do they have a hard time making decisions; can't seem to think or remember?
H. Are they thinking of suicide or death?
5. Are there periods where rage or excitability seem to last for hours or days or do you seem the opposite of depressed where they 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 their mood is abnormally irritable, elevated or uninhibited?
B. During these periods do they seem to have an inflated self-esteem or feel extra special?
C. During these periods do they seem to need much less sleep or appear rested after only 3 hours, etc.?
D. During these periods are they much more talkative and does their 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 they much more distractible during these periods?
G. Do they have much more energy to complete tasks, achieve conquests or gain accomplishments?
H. Have they been physically aggressive during these specific periods?
I. Do they become involved in pleasurable activities that have a high potential for painful consequences?
Does you child appear nervous or fearful in situations where another child his or her age may not? Does you child have fears or worries that seem to cause significant distress?
NO
YES
Rows
Never
Some
Often
Very Ofte
A. Express fears that appear excessive or unreasonable for their age?
B. These fears come about when they 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 the child to "freeze," or have tantrums, or be clingy
E. The object or situation is avoided or endured with intense anxiety or distress
F. The child recognizes 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 they have unusual or uncomfortable thoughts, images or impulses that enter into their mind and cause distress (Note: These are not simply excessive worries about real-life problems)?
I. Do they attempt to ignore or suppress the thoughts/images by doing rituals or repeated "magical" acts or thoughts ?
J. Do they realize that the thoughts/images are a product of their 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 their life?
O. When separation is anticipated or occurs, is there excessive and recurrent distress?
P. Do they 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. Does your child pull their own hair, resulting in noticeable hair loss?
YES
NO
8. Does your child seem to worry excessively about many things at once (school performance, the future etc.), rather than just one area, as described above? If so, do they seem to have difficulty controlling the worry. Are they irritable and almost physically affected by the worry (restless, fatigued, tensed muscles, can't sleep etc.)?
YES
NO
9. Does your child 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 they have an intense fear that you may embarrass yourself?
YES
NO
10. Does your child refuse to speak in specific social situations when they would be expected to speak (not due to stuttering or not knowing the language etc.)
YES
NO
11. Does your child always 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. Has your child suddenly lost the ability to use an arm or a leg, or to feel, or see without any medical explanation
YES
NO
13. Has your child been exposed to a trauma where they were threatened of death or serious injury, or witnessed a similar circumstance? If so, did they respond with fear, helplessness, horror, or disorganized/agitated behavior
NO
YES
Answer A Through F
Rows
Never
Some
Often
Very Often
A. Does your child 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 they seem to avoid things that are associated with the trauma
F. Are they more aroused or agitated since the trauma can't sleep, outbursts of anger, startle easy, etc.
14. Does your child frequently awaken with bad dreams where they can recall these dreams upon awakening? Do these dreams then involve, usually in great detail, threats to 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. Does your child frequently awaken at night with a panicky scream where they may be sweating, breathing fast and appearing frightened? Or, do they sleepwalk so frequently as to cause distress at home or with daytime activities? If so, does your child appear unresponsive and not remember even having the "bad dream?
YES
NO
16. Has your child ever expressed a real and persistent interest in being the opposite sex? If so, did it get to the point where they consistently dressed as the opposite sex, took on the "role" of the opposite sex and express discomfort with being their own sex?
YES
NO
17. Do you suspect (or has it been documented) that reading, mathematics or writing skills are substantially low for their age or level?
YES
NO
Please explain your answer to question 17
18. Have you or has anyone noted persistent problems with coordination or clumsiness?
YES
NO
19. Have you or has anyone noticed problems with your child 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 of their own age?
YES
NO
20. Has your child had trouble making speech sounds, words, or do they stutter? If so, is this frequent enough to interfere with social communication?
YES
NO
21. If your child is at least 4 years-old, do they have trouble soiling themselves frequently (at least once per month for 3 months and not due directly to a specific medical problem or medication)?
YES
NO
22. If your child is at least 5 years old, do they have trouble wetting themselves frequently (including nighttime, at least twice per week, and not due directly to a specific medical condition or medication?
YES
NO
23. Do you notice any twitches, tics, noises that your child makes that might be repetitive and recurrent (this may be eye blinking, facial or arm twitches, throat clearing, etc.) Note: Not nail biting, knee "bouncing" or other voluntary movements or activities.
YES
NO
Please explain your "yes" answer to question 23.
24. Does your child appear odd or peculiar? If so, do they have trouble relating normally to others, have odd speech or communication, and is unable to demonstrate warmth or affection. Do they manifest repetitive behaviors or have very narrow interests?
YES
NO
Rows
Never
Some
Often
Very Often
A. They show significant problems in the quality of social interaction (they don't relate to peers, they don't use body language, they don't enjoy interacting with people, they don't laugh and smile when others do, etc.)?
B. There are problems with communication quality (severe delay in language development, can't start or maintain a conversations, weird use of linage, lack of spontaneous social play)?
C. There are restrictive or very repetitive interests or behaviors (a child who likes to play with bits of paper to the exclusion of other toys, for example, and they might inflexibly adhere to these behaviors)?
D. Imaginative play, social interaction, and communication were not "normal" or unusual before age 3
E. There has been a loss of purposeful hand skills and problems with trunk and torso coordination.
25. Does your child have a great deal of concern about their weight? If so, are they over concerned with becoming fat, gaining weight, or do they overeat and make themselves vomit etc.?
NO
YES
Rows
Never
Some
Often
Very Often
A. Do they refuse to maintain body weight at or above a "normal" body weight for their age and height?
B. Is there an intense fear of gaining weight or becoming fat, even though underweight?
C. Do they not see themselves as underweight, or do they deny the seriousness of your low body weight, or place undue influence of body weight or shape on their self-evaluation?
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 these episodes?
F. Are there recurrent episodes of behavior in an attempt to prevent weight gain such as vomiting, misuse of laxatives, fasting or excessive exercise?
26. Does your child use alcohol, drugs, or inhalants?
NO
YES
Rows
Never
Some
Often
Very Often
A. The use of these substances causes failure to fulfill obligations at home, work, or school.
B. There is use in situations where it may be physically hazardous.
C. There are recurrent substance-related legal problems.
D. There is use despite it causing social or interpersonal problems or conflicts
E. There are withdrawal sensations when substances are decreased or stopped, or substances are taken to avoid withdrawal
F. There are expressed desires or unsuccessful attempts to cut down or control use.
G. Time is spent in 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 substance use.
I. The substance is used despite knowledge of physical or psychological problems caused or made worse by the substance.
27. Does your child see or hear things that others don't hear or see?
YES
NO
28. Does your child have disorganized speech, or do they seem to be "not quite right" (rarely smiling or speaking, rarely getting out and being around others, etc.)? Note: not during just during an obvious depressive episode.
YES
NO
29. Does your child have unusual beliefs or perceptions that defy logic and your family's beliefs
YES
NO
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