Symptoms Questionnaire for Parents

Please answer all questions below about your child; then print the completed page to bring to the child’s appointment.

Click on the Appropriate Rating: Never Mild Often Severe
1. Poor attention to details
2. Careless mistakes in academic or other activities
3. Short attention span to tasks or play activities
4. Seems not to listen when spoken to
5. Difficulties following through and finishing tasks
6. Poor organization skills, procrastinates, takes a long time to start work
7. Avoids tasks requiring attention (homework, reading)
8. Loses and forgets things (school assignments, pencils, books)
9. Easily distracted (by external stimuli)
10. Forgetful in daily activities
11. Fidgets hands or squirms in seat
12. Gets up from chair inappropriately (can’t stay seated for a long time)
13. Runs, climbs excessively, notably overactive
14. Difficulties playing quietly
15. Up and on the go (as if driven by a motor)
16. Talks excessively
17. Answers before question completed
18. Difficulties waiting turn
19. Interrupts or intrudes into conversation or activity
20. Eating difficulties
21. Sleeping difficulties
22. Headaches
23. Bed wetting
24. Speech delay (current or history of speech delay)
25. Abdominal pain or diarrhea
26. Anxiety (excessive fear) afraid of new situations
27. Depressed mood (unhappy child, cries easily, irritable)
28. Compulsive behavior (rituals, arranging objects, etc.)
29. Oppositional and defiant (refuses to cooperate, answers back, disobedient)
30. Cruel
31. Social difficulties (mocked by other kids), likes to be on his own
32. Very “difficult” child
33. Mood swings
34. Feels easily hurt or cheated
35. Risk taking behaviors, hitting, throwing, runs to street, plays with fire
36. Tics, eye blinking, facial twitches
37. Spacing out, blank stare, in his own world
38. Destroys toys or property
39. Lies frequently
40. Picks on things (nails, clothing)
41. Wants to run things

Be sure to PRINT out the completed version before closing this page.