WURS IBHG
AS A CHILD I WAS OR HAD/have
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Patient Name  *
Date of Birth *
MM
/
DD
/
YYYY
NOT AT ALL OR SLIGHTLY -0
MILDLY-1
MODERATELY-2
QUITE A BIT-3
VERY MUCH-4
Easily distracted
Anxious worrying
Nervous fidgety
Inattentive daydreaming
Hot- or short-tempered
Temper outbursts tantrums
Trouble not finishing things
Stubborn strong-willed
Sad or blue depressed
Disobedient with parents
Low opinion of myself
Irritable
Moody ups and downs
Angry
Impulsive, acting without thinking
Tendency to be immature
Guilty feelings regretful
Losing control of myself
Tendency to be or act irrational
Unpopular, not very friendly
Trouble seeing someone else`s view
Trouble with authorities
Overall a poor student
Trouble with math or numbers
Not achieving up to potential
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