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Child's Name *

Date of Birth: *

Gender *

Form Completed By: *

Relationship to Child: *

For Each item below, check the one category that describes your child DURING THE PAST 6 MONTHS *

	None = the child never or very rarely exhibits this behavior	Mild = the child exhibits this behavior approximately once per week, and few other notice or complain about this behavior	Moderate = the child exhibits this behavior at least three times per week, and others notice or comment on this behavior	Severe = the child exhibits this behavior almost daily, multiple other complain about this behavior	Past = the child used to have significant problems with this behavior, BUT NOT DURING THE PAST 6 MONTHS
1. Has difficulty separating from parents* (* = or major caregiver/guardian)
2. Worries excessively about losing or harm occurring to parents*
3. Worries about being separated from parent* (getting lost or kidnapped)
4. Resists going to school or elsewhere because of fears of separation
5. Resists being alone or without parents*
6. Has difficulty going to sleep without parent nearby
7. Physical complaints (headache, stomach ache, nausea) when anticipating separation
8. Has discrete periods of intense fear that peak within 10 minutes
9. Has excessive, unreasonable fear of a specific object or situation
10. Has recurrent thoughts that cause marked distress (e.g., fears germs)
11. Driven to perform repetitive behaviors (e.g., handwashing doing things 3 times)
12. Has recurrent, distressing recollections of past difficult or painful events
13. Worries excessively about multiple things (e.g., school, family, health, etc.)
14. Goes to the bathroom at inappropriate times or places
15. Makes noises, and is often unaware of them
16. Makes repetitive, sudden, nonrhythmic movements
17. Fails to pay close attention to details or makes careless mistakes
18. Has difficulty sustaining attention during play or school activities
19. Does not seem to listen when spoken to directly
20. Does not follow through on instructions; fails to finish schoolwork/chores
21. Has difficulty organizing tasks and activities
22. Loses things necessary for tasks are activities (toys, pencils, etc.)
23. Is easily distracted easily by irrelevant stimuli
24. Is forgetful in daily activities
25. Is fidgety or squirms in seat
26. Has difficulty remaining seated
27. Runs or climbs excessively; is restless
28. Talks excessively
29. Blurts out answers before questions have been completed
30. Has difficulty waiting turn
31. Interrupts or intrude on others
32. Episodes of unusually elevated or irritable mood
33. During this episode, grandiosity or markedly inflated self-esteem (Superhero)
34. During this episode, is more talkative than usual/seems pressured to keep talking
35. During this episode, races from thought to thought
36. During this episode, is very distractible
37. During this episode, excessively involved in things (too religious, hypersexual)
38. During this episode, dangerous involvement in pleasurable activity (spending, sex)
39. Depressed or irritable mood most of the day, most days for at least 1 week
40. Loss of interest in previously enjoyable activities
41. Notable change in appetite (not when dieting or trying to gain weight)
42. Difficulty falling or staying asleep, or sleeping excessively through the day
43. Others notice child is sluggish or agitated most of the time
44. Loss of energy nearly everyday
45. Feelings of worthlessness or inappropriate guilt nearly everyday
46. Thinks about dying or wouldn't care if died
47. Smokes cigarettes, drinks alcohol, OR abuses drugs (circle all that apply)
48. Has bad things happen when under the influence of substances
49. Has made unsuccessful efforts to stop using a substance
50. Is excessively worried about gaining weight, even though underweight
51. If female, has stopped having menstrual cycles (after regularly having)
52. Thinks he/she is fat, even though not overweight (pulls skin and claims is fat, etc.)
53. Engages in bringing and purging (eats excessively, then vomits or uses laxatives)
54. Bullies, threatens, or intimidates others
55. Initiates physical fights
56. Uses weapons that could harm others
57. Has been physically cruel to animals
58. Has shoplifted or stolen items
59. Has deliberately set fires
60. Has deliberately destroyed others' property
61. Lies to obtain goods or to avoid obligations
62. Stays out at night despite parental prohibitions
63. Has run away from home overnight on at least two occasions
64. Is truant from school
65. Loses temper
66. Actively defies or refuses to comply with adult rules
67. Deliberately annoys others
68. Blames others for his/her mistakes or misbehavior
69. Easily annoyed by others
70. Is spiteful or vindictive
71. Has unusual thoughts that others cannot understand or believe
72. Hears voices speaking to him/her that others don't hear
73. Does poorly at sports or games requiring coordination skills
74. Has difficulty at school with: reading, writing, math, spelling (Circle all that apply)
75. Has delayed speech or has limited language now
76. Avoids eye contact during conversations
77. Does not follow when others point to objects
78. Shows little interest in others; emotionally out of sync with others
79. Difficulty starting, stopping conversation; continues talking after others lose interest
80. Uses unusual phrases, possibly over and over (speaks Disney or movie lines)
81. Does not engage in make-believe play; plays more alone than with others
82. Unusual preoccupations with objects or unusual routines (lines up 100's of cars, etc.)
83. Difficulty with transitions; may be inflexible about adhering to routines or rules
84. Shows unusual physical mannerism (hand-flapping, shrieks, objects in mouth, etc. )
85. Unusual preoccupations (schedules, own alphabet, weather reports, etc.)

Thank you for answering each of these items. Please list any other symptoms that concern you: