Instructions:
My child has and/or had the following symptoms and/or behaviors.
You may have noticed a behavior as far back as early childhood
or you may have observed it more recently. In either case, estimate
how frequently the behavior has occurred since you first noticed
it. In other words, please rate these symptoms and/or behaviors as they were at their most severe and/or prior to your child starting medication. Then select a number in the “Frequency” column using the following key, to represent the frequency of occurrence:
| Never or hardly ever |
Sometimes |
Often |
Very often or
almost constantly |
| 1 |
2 |
3 |
4 |
|
| Symptom/Behavior |
Frequency
|
| |
1 |
2 |
3 |
4 |
| 1) displays excessive distress when separated from family |
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| 2) exhibits excessive anxiety or worry |
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| 3) has difficulty arising in the AM |
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| 4) is hyperactive and easily excited in the PM |
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| 5) has difficulty settling at night |
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| 6) has difficulty getting to sleep |
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| 7) sleeps fitfully and/or awakens in the middle of the night |
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| 8) has night terrors and/or nightmares |
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| 9) wets bed |
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| 10) craves sweet-tasting foods |
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| 11) is easily distracted by extraneous stimuli |
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| 12) is easily distracted during repetitive chores & lessons |
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| 13) demonstrates inability to concentrate at school |
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| 14) attempts to avoid homework assignments |
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| 15) able to focus intently on subjects of interest and yet at times is easily distractible |
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| 16) has poor handwriting |
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| 17) has difficulty organizing tasks |
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| 18) has dfficulty making transitions |
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| 19) has difficulty estimating time |
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| 20) has auditory processing or short-term memory deficit |
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| 21) is extremely sensitive to textures of clothes, labels, and tightness of fit of socks or shoes |
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| 22) exhibits extreme sensitivity to sound and noise |
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| 23) complains of body temperature extremes or feeling hot despite neutral ambient temperature |
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| 24) is easily excitable |
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| 25) has periods of high, frenetic energy and motor activation |
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| 26) has many ideas at once |
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| 27) interrupts or intrudes on others |
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| 28) has periods of excessive and rapid speech |
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| 29) has exaggerated ideas about self or abilities |
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| 30) tells tall tales; embellishes or exaggerates |
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| 31) displays abrupt, rapid mood swings |
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| 32) has irritable mood states |
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| 33) has elated or silly, goofy, giddy mood states |
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| 34) displays precocious sexual curiousty |
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| 35) exhibits inappropriate sexual behaviors, e.g. openly touches self or others’ private parts |
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| 36) takes excessive risks |
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| 37) complains of being bored |
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| 38) has periods of low energy and/or withdraws or isolates self |
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| 39) has decreased initiative |
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| 40) experiences periods of self doubt and poor self-esteem |
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| 41) feels easily criticized and/or rejected |
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| 42) feels easily humiliated or shamed |
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| 43) fidgets with hands or feet |
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| 44) is intolerant of delays |
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| 45) relentlessly pursues own needs and is demanding of others |
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| 46) is willful and refuses to be subordinated by others |
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| 47) argues with adults |
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| 48) is bossy towards others |
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| 49) defies or refuses to comply with rules |
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| 50) blames others for his/her mistakes |
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| 51) is easily angered in response to limit setting |
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| 52) lies to avoid consequences of his/her actions |
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| 53) has protracted, explosive temper tantrums |
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| 54) has difficulty maintaining friendships |
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| 55) displays aggressive behavior towards others |
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| 56) has destroyed property intentionally |
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| 57) curses viciously, uses foul language in anger |
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| 58) makes moderate threats to others or self |
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| 59) makes clear threats of violence to others or self |
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| 60) has made clear threats of suicide |
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| 61) is fascinated with gore, blood, or violent imagery |
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| 62) has acknowledged experiencing auditory and/or visual hallucinations |
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| 63) hoards or avidly seeks to collect objects or food |
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| 64) has concern with dirt, germs, or contamination |
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| 65) is very intuitive and/or very creative |
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