Circle each item as 1, somewhat true; 2, mostly true; or 0, not true of your child in the past three months.
1. 0 1 2 Disobedient at home
2. 0 1 2 Disobedient at school
3. 0 1 2 Denies problematic behavior
4. 0 1 2 Doesn’t like rules
5. 0 1 2 Trouble learning
6. 0 1 2 Clowns around a lot
7. 0 1 2 Lost in thoughts
8. 0 1 2 Can’t finish things
9. 0 1 2 Argues a lot
10. 0 1 2 Cheats in games
11. 0 1 2 Uses bad language
12. 0 1 2 Lies a lot
13. 0 1 2 Steals
14. 0 1 2 Destroys possessions
15. 0 1 2 Cruel to animals
16. 0 1 2 Drinks alcohol
17. 0 1 2 Uses drugs
18. 0 1 2 Lacks energy
19. 0 1 2 Sad and unhappy
20. 0 1 2 Irritable
21. 0 1 2 Moody
22. 0 1 2 Has thoughts of killing self
23. 0 1 2 Acts to get attention
27. 0 1 2 Acts first, thinks later
28. 0 1 2 Hyperactive
29. 0 1 2 Bosses or bullies others
30. 0 1 2 Aggressive with peers
31. 0 1 2 Few friends
32. 0 1 2 Feels inferior
33. 0 1 2 Clumsy
34. 0 1 2 Nervous habits
35. 0 1 2 Needs everything in its place
36. 0 1 2 Accident prone
37. 0 1 2 Has aches and pains
38. 0 1 2 Overly shy
39. 0 1 2 Too dependent on adults
40. 0 1 2 Jealous of siblings
41. 0 1 2 Whines
42. 0 1 2 Problems with speech
43. 0 1 2 Uses baby talk
44. 0 1 2 Eats too much
45. 0 1 2 Eats too little
46. 0 1 2 Wets the bed
47. 0 1 2 Wets during the day
48. 0 1 2 Soils him/herself
24. 0 1 2 Difficulty with sleep: Can’t get to sleep _____ ; Can’t stay asleep _____ .
25. 0 1 2 Fears things (e.g., bugs, animals). What? ________________________________
26. 0 1 2 Worries a lot. What about? ___________________________________________
Other problems:
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