Pediatric Symptom Checklist
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’s behavior, emotions, or learning, you may help your child get the best care possible by answering these questions.
Please indicate which statement best describes your child.  0=Never;  1= Sometimes;  2= Often
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Patient Name *
Your Name *
Relation to patient? *
0=Never;  1= Sometimes;  2= Often
1. Complains of aches and pains *
Never
Often
2. Spends more time alone *
Never
Often
3. Tires easily, has little energy *
Never
Often
4. Fidgety, unable to sit still *
Never
Often
5. Has trouble with teacher *
Never
Often
6. Less interested in school *
Never
Often
7. Acts as if driven by a motor *
Never
Often
8. Daydreams too much *
Never
Often
9. Distracted easily *
Never
Often
10. Is afraid of new situations *
Never
Often
0=Never;  1= Sometimes;  2= Often
11. Feels sad, unhappy *
Never
Often
12. Is irritable, angry *
Never
Often
13. Feels hopeless *
Never
Often
14. Has trouble concentrating *
Never
Often
15. Less interested in friends *
Never
Often
16. Fights with other children *
Never
Often
17. Absent from school *
Never
Often
18. School grades dropping *
Never
Often
19. Is down on him or herself *
Never
Often
20. Visits the doctor with doctor finding nothing wrong *
Never
Often
0=Never;  1= Sometimes;  2= Often
21. Has trouble sleeping *
Never
Often
22. Worries a lot *
Never
Often
23. Wants to be with you more than before *
Never
Often
24. Feels he or she is bad *
Never
Often
25. Takes unnecessary risks *
Never
Often
26. Gets hurt frequently *
Never
Often
27. Seems to be having less fun *
Never
Often
28. Acts younger than children his or her age *
Never
Often
29. Does not listen to rules *
Never
Often
30. Does not show feelings *
Never
Often
0=Never;  1= Sometimes;  2= Often
31. Does not understand other people’s feelings *
Never
Often
32. Teases others *
Never
Often
33. Blames others for his or her troubles *
Never
Often
34. Takes things that do not belong to him or her *
Never
Often
35. Refuses to share *
Never
Often
Reference:
This Pediatric Symptom Checklist was written by J. Michael Murphy, Ed.D, and endorsed by the American Academy of Pediatrics. You can find it at www.Brightfutures.org.  

M.S. Jellinek and J.M. Murphy, Massachusetts General Hospital

https://www.massgeneral.org/psychiatry/services/treatmentprograms.aspx?id=2088&display=overview 
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