48 Pictorial Pediatric Symptom Checklist - 17 __________________________________ _________________ _________________ Child’s Name Date of Birth Today’s Date Please mark under the heading that best fits your child: Fidgety, unable to sit still Acts as if driven by a motor Daydreams too much Distracted easily Feels sad, unhappy 1 2 3 4 5 NEVER SOMETIMES OFTEN NEVER SOMETIMES OFTEN NEVER SOMETIMES OFTEN NEVER SOMETIMES OFTEN NEVER SOMETIMES OFTEN © 2005 Jellinek M (as adapted with permission by Gardner W and Leiner M, Shirsat P, and MezaT). Permission is granted to reproduce this page. Keep Going! Ú
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48
Pictorial Pediatric Symptom Checklist - 17
__________________________________ _________________ _________________Child’sName DateofBirth Today’sDate
Pleasemarkundertheheadingthatbestfitsyourchild:
Fidgety,unabletositstill
Actsasifdrivenbyamotor
Daydreamstoomuch
Distractedeasily
Feelssad,unhappy
1
2
3
4
5
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
©2005JellinekM(asadaptedwithpermissionbyGardnerWandLeinerM,ShirsatP,andMezaT).Permissionisgrantedtoreproducethispage. KeepGoing! Ú
49
Feelshopeless
Hastroubleconcentrating
Fightswithotherchildren
Isdownonhimorherself
Worriesalot
6
7
8
9
10
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
Seemstobehavinglessfun
NEVER SOMETIMES OFTEN
11
©2005JellinekM(asadaptedwithpermissionbyGardnerWandLeinerM,ShirsatP,andMezaT).Permissionisgrantedtoreproducethispage. KeepGoing! Ú
50
Doesnotlistentorules
Doesnotunderstandotherpeople’sfeelings
Teasesothers
Blamesothersforhisorhertroubles
Takesthingsthatdonotbelongtohimorher16
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
NEVER SOMETIMES OFTEN
Refusestoshare
NEVER SOMETIMES OFTEN
17
Forofficeuseonly-----------------------------------------------------------------------Factor1_______
Factor2_______
Factor3______
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13
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15
©2005JellinekM(asadaptedwithpermissionbyGardnerWandLeinerM,ShirsatP,andMezaT).Permissionisgrantedtoreproducethispage.
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