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 obsessed by unpleasant 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 often seems sad      □         □      □
21   He is often in a black mood (“depressed”)      □         □      □
22   He says or shows that he is not happy      □         □      □
23   He shows no interest, not even in pleasant things      □         □      □
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 or 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   □   □   □

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