| 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 | □ | □ | □ |