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Pediatric Symptom Checklist (PSC-17)
To be completed by PATIENT.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Please mark under the heading that best fits you:
*
Rows
Never
Sometimes
Often
1. Feel sad, unhappy
2. Feel hopeless
3. Down on yourself
4. Worry a lot
5. Seem to be having less fun
6. Fidgety, unable to sit still
7. Daydream too much
8. Distracted easily
9. Have trouble concentrating
10. Act as if driven by motor
11. Fight with other children
12. Do not listen to rules
13. Do not understand other people’s feelings
14. Tease others
15. Blame others for your troubles
16. Refuse to share
17. Take things that do not belong to you
Score: Internalizing
1-5
Score: Attention
6-10
Score: Externalizing
11-17
Score: Total
Do you have any emotional or behavioral problems for which you want help?
*
No
Yes
Are you currently seeing a mental health counselor?
*
No
Yes
Submit
Should be Empty: