Please fill out this form to reflect your view of the child's behavior, even if other people might not agree. Feel free to write additional comments beside each item and in the space provided on page 2.
Be sure to answer all items. Below is a list of items that describe children. For each item that describes the child now or within the past 2 months. Please answer
all items as well as you can, even if some do not seem to apply to the child.
Question
Answer
Comment
1. Aches or pains (without medical cause; do not include stomach or headaches)
2. Acts too young for age
3. Afraid of new things
4. Avoids looking others in the eye
5. Can't concentrate, can't pay attention for long
6. Can't sit still, restless, or hyperactive
7. Can't stand having things out of place
8. Can't stand waiting; wants everything now
9. Chews on things that aren't edible
10. Clings to adults or too dependent
11. Constantly seeks help
12. Apathetic or unmotivated
13. Cries a lot
14. Cruel to animals
15. Defiant
16. Demands must be met immediately
17. Destroys his/her own things
18. Destroys property belonging to others
19. Daydreams or gets lost in his/her thoughts
20. Disobedient
21. Disturbed by any change in routine
22. Cruelty, bullying, or meanness to others
23. Doesn't answer when people talk to him/her
24. Difficulty following directions
25. Doesn't get along with other children
26. Doesn't know how to have fun; acts like a little adult
27. Doesn't seem to feel guilty after misbehaving
28. Disturbs other children
29. Easily frustrated
30. Easily jealous
31. Eats or drinks things that are not food -- do not include sweets (describe in comment section)
32. Fears certain animals, situations, or places other than daycare of school (describe in comments)
33. Feelings are easily hurt
34. Gets hurt a lot, accident-prone
35. Gets in many fights
36. Gets into everything
37. Gets too upset when separated from parents
38. Explosive and unpredictable behavior
39. Headaches (without medical cause)
40. Hits others
41. Holds his/her breath
42. Hurts animals or people without meaning to
43. Looks unhappy without good reason
44. Angry moods
45. Nausea, feels sick (without medical cause)
46. Nervous movements or twitching (describe in comments)
