Pediatric Symptom Checklist
Screening tool for identifying emotional and behavioral symptoms in children
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Parent/Guardian Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Guardian
Other
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Checklist Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate how often your child has experienced the following symptoms in the past month.
*
Rows
Never
Sometimes
Often
Complains of aches and pains
1
2
3
Spends more time alone
4
5
6
Tires easily, little energy
7
8
9
Fidgety, unable to sit still
10
11
12
Has trouble with teacher
13
14
15
Less interested in school
16
17
18
Acts as if driven by a motor
19
20
21
Daydreams too much
22
23
24
Distracted easily
25
26
27
Is afraid of new situations
28
29
30
Are there any other concerns or symptoms you would like to mention?
Submit Checklist
Should be Empty: