CBC Pediatric Symptom Checklist (PSC) – Parent Pediatric Symptom Checklist Child's name* First Last Child's date of birth* MM slash DD slash YYYY Today's date* MM slash DD slash YYYY Please select the answer that best describes your child: 1. Complains of aches and pains* Always Sometimes Never 2. Spends more time alone* Always Sometimes Never 3. Tires easily, has little energy* Always Sometimes Never 4. Fidgety, unable to sit still* Always Sometimes Never 5. Has trouble with teacher* Always Sometimes Never 6. Less interested in school* Always Sometimes Never 7. Acts as if driven by a motor* Always Sometimes Never 8. Daydreams too much* Always Sometimes Never 9. Distracted easily* Always Sometimes Never 10. Is afraid of new situations* Always Sometimes Never 11. Feels sad, unhappy* Always Sometimes Never 12. Is irritable, angry* Always Sometimes Never 13. Feels hopeless* Always Sometimes Never 14. Has trouble concentrating* Always Sometimes Never 15. Less interested in friends* Always Sometimes Never 16. Fights with other children* Always Sometimes Never 17. Absent from school* Always Sometimes Never 18. School grades dropping* Always Sometimes Never 19. Is down on him or herself* Always Sometimes Never 20. Visits the doctor with doctor finding nothing wrong* Always Sometimes Never 21. Has trouble sleeping* Always Sometimes Never 22. Worries a lot* Always Sometimes Never 23. Wants to be with you more than before* Always Sometimes Never 24. Feels he or she is bad* Always Sometimes Never 25. Takes unnecessary risks* Always Sometimes Never 26. Gets hurt frequently* Always Sometimes Never 27. Seems to be having less fun* Always Sometimes Never 28. Acts younger than children his or her age* Always Sometimes Never 29. Does not listen to rules* Always Sometimes Never 30. Does not show feelings* Always Sometimes Never 31. Does not understand other people's feelings* Always Sometimes Never 32. Teases others* Always Sometimes Never 33. Blames others for his or her troubles* Always Sometimes Never 34. Takes things that do not belong to him or her* Always Sometimes Never 35. Refuses to share* Always Sometimes Never TotalCalculated – do not edit
