SBHC Pediatric Symptom Checklist (PSC) – Youth SBHC Pediatric Symptom Checklist (PSC) 06-01-2020 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 you: 1. Complain of aches and pains* Always Sometimes Never 2. Spend more time alone* Always Sometimes Never 3. Tire easily, has little energy* Always Sometimes Never 4. Fidgety, unable to sit still* Always Sometimes Never 5. Have trouble with teacher* Always Sometimes Never 6. Less interested in school* Always Sometimes Never 7. Act as if driven by a motor* Always Sometimes Never 8. Daydream too much* Always Sometimes Never 9. Distract easily* Always Sometimes Never 10. Are afraid of new situations* Always Sometimes Never 11. Feel sad, unhappy* Always Sometimes Never 12. Are irritable, angry* Always Sometimes Never 13. Feel hopeless* Always Sometimes Never 14. Have trouble concentrating* Always Sometimes Never 15. Less interested in friends* Always Sometimes Never 16. Fight with other children* Always Sometimes Never 17. Absent from school* Always Sometimes Never 18. School grades dropping* Always Sometimes Never 19. Down on yourself* Always Sometimes Never 20. Visit doctor with doctor finding nothing wrong* Always Sometimes Never 21. Have trouble sleeping* Always Sometimes Never 22. Worry a lot* Always Sometimes Never 23. Want to be with parent more than before* Always Sometimes Never 24. Feel that you are bad* Always Sometimes Never 25. Take unnecessary risks* Always Sometimes Never 26. Get hurt frequently* Always Sometimes Never 27. Seem to be having less fun* Always Sometimes Never 28. Act younger than children your own age* Always Sometimes Never 29. Do not listen to rules* Always Sometimes Never 30. Do not show feelings* Always Sometimes Never 31. Do not understand other people's feelings* Always Sometimes Never 32. Tease others* Always Sometimes Never 33. Blame others for your troubles* Always Sometimes Never 34. Take things that do not belong to you* Always Sometimes Never 35. Refuse to share* Always Sometimes Never 36. During the past three months, have you thought of killing yourself?* No Yes 37. Have you ever tried to kill yourself?* No Yes Total Calculated – do not edit
