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Pediatric Symptom Checklist (PSC-17)
To be completed by PARENT.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Please mark under the heading that best describes your child:
*
Rows
Never
Sometimes
Often
Feels sad, unhappy
2. Feels hopeless
3. Is down on self
4. Worries a lot
5. Seems to be having less fun
6. Fidgety, unable to sit still
7. Daydreams too much
8. Distracted easily
9. Has trouble concentrating
10. Acts as if driven by a motor
11. Fights with other children
12. Does not listen to rules
13. Does not understand other people’s feelings
14. Teases others
15. Blames others for his/her troubles
16. Refuses to share
17. Takes things that do not belong to him/her
Score
Does your child have any emotional or behavioral problems for which she/he needs help?
*
No
Yes
Submit
Should be Empty: