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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. Fidgety, unable to sit still
2. Feel sad, unhappy
3. Daydream too much
4. Refuse to share
5. Do not understand other people’s feelings
6. Feel hopeless
7. Have trouble concentrating
8. Fight with other children
9. Down on yourself
10. Blame others for your troubles
11. Seem to be having less fun
12. Do not listen to rules)
13. Act as if driven by motor
14. Tease others
15. Worry a lot
16. Take things that do not belong to you
17. Distracted easily
Score
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: