Very True | Somewhat or Sometimes True |
Not True | ||
---|---|---|---|---|
1 | Your son/daughter often complains about some physical discomfort (for example: a headache, stomach ache, etc.) | □ | □ | □ |
2 | He is excessively worried about illnesses and/or that he will get ill | □ | □ | □ |
3 | He finds it difficult to fall asleep or says he does not sleep well | □ | □ | □ |
4 | His sleep is disturbed by nightmares or waking up during the night | □ | □ | □ |
5 | He appears tense and/or anxious | □ | □ | □ |
6 | He tends to worry about everything | □ | □ | □ |
7 | He worries about school too much | □ | □ | □ |
8 | It is hard for him to be separated or far from his parents | □ | □ | □ |
9 | He is excessively shy | □ | □ | □ |
10 | He is usually embarrassed around strangers or people he does not know very well | □ | □ | □ |
11 | He is excessively afraid of something (e.g. the dark, being alone, insects, thieves) Specify what he is afraid of | □ | □ | □ |
12 | He is excessively afraid of dirt, so he has to wash continually | □ | □ | □ |
13 | There are repetitive actions or “rituals” that he frequently repeats and he says he cannot help doing them, If yes, describe which ones | □ | □ | □ |
14 | He has an obsessive need for things to be in a precise order | □ | □ | □ |
15 | He is vepleasant thoughts and cannot free himself from them | □ | □ | □ |
16 | He is very afraid of making mistakes | □ | □ | □ |
17 | It is hard for him to make decisions, even about unimportant things | □ | □ | □ |
18 | Has he ever been involved in or witnessed particularly stressful events, after which his behaviour changed in some way? If true, indicate what behavioural changes occurred after the event | □ | □ | □ |
19 | He cries for no reason or about unimportant things | □ | □ | □ |
20 | He is often in a black mood (“depressed”) | □ | □ | □ |
21 | He says or shows that he is not happy | □ | □ | □ |
22 | He shows no interest, not even in pleasant things | □ | □ | □ |
23 | He shows no interest, not even in pleasant thibgs | □ | □ | □ |
24 | He feels inferior to others; he has low self-esteem | □ | □ | □ |
25 | He is often tired or listless; everything exhausts him | □ | □ | □ |
26 | He blames himself too much | □ | □ | □ |
27 | He has sometimes said he does not want to live any longer | □ | □ | □ |
28 | He has hurt himself or tried to hurt himself | □ | □ | □ |
29 | He is very irritable | □ | □ | □ |
30 | He often gets angry, even about unimportant things | □ | □ | □ |
31 | He has frequent mood changes | □ | □ | □ |
32 | He is quick-tempered and has fits of anger | □ | □ | □ |
33 | He does not obey and it is difficult to make him obey | □ | □ | □ |
34 | He does not follow the rules | □ | □ | □ |
35 | He often tells lies or cheats | □ | □ | □ |
36 | He is domineering and always wants to assert himself | □ | □ | □ |
37 | He quarrels frequently | □ | □ | □ |
38 | He bothers and intentionally annoys others | □ | □ | □ |
39 | He often hits people | □ | □ | □ |
40 | He destroys things | □ | □ | □ |
41 | He is or has been cruel to animals or people | □ | □ | □ |
42 | He has committed petty theft | □ | □ | □ |
43 | He is impulsive and acts before thinking | □ | □ | □ |
44 | He tends not to take turns when he is playing | □ | □ | □ |
45 | He interrupts, disturbing games and others’ conversations | □ | □ | □ |
46 | He is always moving around and cannot stay still | □ | □ | □ |
47 | He cannot sit down for a long time but has to get up | □ | □ | □ |
48 | He runs and jumps everywhere in an exaggerated way | □ | □ | □ |
49 | He has trouble concentrating while doing his homework | □ | □ | □ |
50 | He has trouble paying attention to something for a long period | □ | □ | □ |
51 | He gets tired very quickly even when he is playing | □ | □ | □ |
52 | He feels persecuted | □ | □ | □ |
53 | He is overly suspicious | □ | □ | □ |
54 | Sometimes he has strange ideas | □ | □ | □ |
55 | Sometimes he says he sees or hears things that are not there | □ | □ | □ |
56 | He has difficulty in relating to and interacting with others | □ | □ | □ |
57 | He cannot make real friends or does not seem interested in doing so | □ | □ | □ |
58 | He does not play willingly with his peers | □ | □ | □ |
59 | He does not seem to express emotions using appropriate facial expressions | □ | □ | □ |
60 | His behaviour is "strange", unlike that of his peers | □ | □ | □ |
61 | He asks inappropriate questions, like overly-personal questions to strangers at inopportune times | □ | □ | □ |
62 | He sometimes wets the bed | □ | □ | □ |
63 | He sometimes dirties his pants during the day | □ | □ | □ |
64 | He stuffs himself with food | □ | □ | □ |
65 | He keeps to a strict diet (not prescribed by a doctor or dietician) | □ | □ | □ |
66 | He feels too fat or says that parts of his body are too fat | □ | □ | □ |
67 | He has recently lost a lot of weight | □ | □ | □ |
68 | He appears to be overly interested in sex | □ | □ | □ |
69 | He shows he would like to be of the opposite sex | □ | □ | □ |
70 | He smokes | □ | □ | □ |
71 | He drinks alcohol | □ | □ | □ |
72 | He uses drugs (smokes hashish or other dangerous substances) | □ | □ | □ |
73 | He does not do well at school | □ | □ | □ |
74 | He has recently done much worse at school | □ | □ | □ |
75 | His classmates or other children make fun of him, threaten or mistreat him | □ | □ | □ |