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Planned Giving
Pediatric Symptom Checklist (PSC-Y) – Youth
Pediatric Symptom Checklist
Child's Name
*
First
Last
Child's Date of Birth
*
Date Format: MM slash DD slash YYYY
Today's date
*
Date Format: 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
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