"*" indicates required fields Parent FormChild's Name* First Last Sex* Boy Girl Child's Date of Birth* MM slash DD slash YYYY Parent/Guardian's name* First Last Today's Date* MM slash DD slash YYYY Was your child born prematurely?* No Yes If yes, what was the expected date of birth. MM slash DD slash YYYY Instructions: Many statements describe normal feelings and behaviors, but some describe feelings and behaviors that may be problems. Please respond to every item. Please select the ONE response that best describes your child's behavior in the LAST MONTH.1. Shows pleasure when he or she succeeds (for example, claps for self).* Not true/Rarely Somewhat true/Sometimes Very true/Often 2. Gets hurt so often that you can't take your eyes off him or her.* Not true/Rarely Somewhat true/Sometimes Very true/Often 3. Seems nervous, tense, or fearful.* Not true/Rarely Somewhat true/Sometimes Very true/Often 4. Is restless and can't sit still.* Not true/Rarely Somewhat true/Sometimes Very true/Often 5. Follows rules.* Not true/Rarely Somewhat true/Sometimes Very true/Often 6. Wakes up at night and needs help to fall asleep again.* Not true/Rarely Somewhat true/Sometimes Very true/Often 7. Cries or has a tantrum until he or she is exhausted.* Not true/Rarely Somewhat true/Sometimes Very true/Often 8. Is afraid of certain places, animals or things.* Not true/Rarely Somewhat true/Sometimes Very true/Often What is he or she afraid of? 9. Has less fun than other children.* Not true/Rarely Somewhat true/Sometimes Very true/Often 10. Looks for you (or other parent) when upset.* Not true/Rarely Somewhat true/Sometimes Very true/Often 11. Cries or hangs onto you when you try to leave.* Not true/Rarely Somewhat true/Sometimes Very true/Often 12. Worries a lot or is very serious.* Not true/Rarely Somewhat true/Sometimes Very true/Often 13. Looks right at you when you say his or her name.* Not true/Rarely Somewhat true/Sometimes Very true/Often 14. Does not react when hurt.* Not true/Rarely Somewhat true/Sometimes Very true/Often 15. Is affectionate with loved ones.* Not true/Rarely Somewhat true/Sometimes Very true/Often 16. Won't touch some objects because of how they feel.* Not true/Rarely Somewhat true/Sometimes Very true/Often 17. Has trouble falling asleep or staying asleep.* Not true/Rarely Somewhat true/Sometimes Very true/Often 18. Runs away in public places.* Not true/Rarely Somewhat true/Sometimes Very true/Often 19. Plays well with other children (not including brother/sister).(Select N if there is no contact with other children)* N Not true/Rarely Somewhat true/Sometimes Very true/Often 20. Can pay attention for a long time (other than when watching TV).* Not true/Rarely Somewhat true/Sometimes Very true/Often 21. Has trouble adjusting to changes.* Not true/Rarely Somewhat true/Sometimes Very true/Often 22. Tries to help when someone is hurt (for example, gives a toy).* Not true/Rarely Somewhat true/Sometimes Very true/Often 23. Often gets very upset.* Not true/Rarely Somewhat true/Sometimes Very true/Often 24. Gags or chokes on food* Not true/Rarely Somewhat true/Sometimes Very true/Often 25. Imitates playful sounds when you ask him or her to.* Not true/Rarely Somewhat true/Sometimes Very true/Often 26. Refuses to eat.* Not true/Rarely Somewhat true/Sometimes Very true/Often 27. Hits, shoves, kicks, or bites children (not including brother/sister).( Select N if there is no contact with other children)* N Not true/Rarely Somewhat true/Sometimes Very true/Often 28. Is destructive. Breaks or ruins things on purpose.* Not true/Rarely Somewhat true/Sometimes Very true/Often 29. Points to show you something far away.* Not true/Rarely Somewhat true/Sometimes Very true/Often 30. Hits, bites, or kicks you (or other parent).* Not true/Rarely Somewhat true/Sometimes Very true/Often 31. Hugs or feeds dolls or stuffed animals.* Not true/Rarely Somewhat true/Sometimes Very true/Often 32. Seems very unhappy, sad, depressed, or withdrawn.* Not true/Rarely Somewhat true/Sometimes Very true/Often 33. Purposely tries to hurt you (or other parent)* Not true/Rarely Somewhat true/Sometimes Very true/Often 34. When upset, gets very still, freezes, or doesn't move.* Not true/Rarely Somewhat true/Sometimes Very true/Often The following statements describe feelings and behaviors that can be problems for young children. Some of the descriptions may be a bit hard to understand, especially if you have not seen the behavior in your child. Please do your best to respond to all statements.35. Puts things in a special order over and over and gets upset if he or she is interrupted.* Not true/Rarely Somewhat true/Sometimes Very true/Often 36. Repeats the same action or phrase over and over without enjoyment* Not true/Rarely Somewhat true/Sometimes Very true/Often Please give an example: 37. Repeats a particular movement over and over without enjoyment (like rocking, spinning).* Not true/Rarely Somewhat true/Sometimes Very true/Often Please give an example: 38. Spaces out. Is totally unaware of what's happening around him or her* Not true/Rarely Somewhat true/Sometimes Very true/Often 39. Does not make eye contact.* Not true/Rarely Somewhat true/Sometimes Very true/Often 40. Avoids physical contact* Not true/Rarely Somewhat true/Sometimes Very true/Often 41. Hurts self on purpose (for example, bangs his or her head).* Not true/Rarely Somewhat true/Sometimes Very true/Often Please describe: 42. Eats or drinks things that are not edible (like paper or paint).* Not true/Rarely Somewhat true/Sometimes Very true/Often Please describe: A. How worried are you about your child's behavior, emotions, or relationships?* Not at all worried A little worried Worried Very worried B. How worried are you about your child's language development?* Not at all worried A little worried Worried Very worried The Problem TotalCalculated- do not editThe Competence TotalCalculated- do not edit
