Pediatric Symptom Checklist-17
Caregiver completing this form
First Name
Last Name
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
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1941
1940
1939
1938
1937
1936
1935
1934
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Name of child
First Name
Last Name
1
Never
Sometimes
Often
Please mark under the heading that best fits your child
2
3
4
1. Fidgety, unable to sit still
5
6
7
2. Feels sad, unhappy
8
9
10
3. Daydreams too much
11
12
13
4. Refuses to share
14
15
16
5. Does not understand other people’s feelings
17
18
19
6. Feels hopeless
20
21
22
7. Has trouble concentrating
23
24
25
8. Fights with other children
26
27
28
9. Is down on him or herself
29
30
31
10. Blames others for his or her troubles
32
33
34
11. Seems to be having less fun
35
36
37
12. Does not listen to rules
38
39
40
13. Acts as if driven by a motor
41
42
43
14. Teases others
44
45
46
15. Worries a lot
47
48
49
16. Takes things that do not belong to him or her
50
51
52
17. Distracted easily
53
54
55
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