Behavior Symptom Checklist printable pdf download

Behavior Symptom Checklist

Please read the following list and rate your child on each behavior. Circle the number which best describes

the frequency of each behavior using the following scale.

Never

Rarely

Occasionally

Frequently

Very Frequently

1 2 3 4 5 Has trouble sleeping

1 2 3 4 5 Seems disorganized, loses things

1 2 3 4 5 Has poor appetite

needed for school

1 2 3 4 5 Seems sad or unhappy

1 2 3 4 5 Takes risks without considering

1 2 3 4 5 Talks about feeling stupid or worthless

the danger involved (e.g.,

1 2 3 4 5 Loses interest in having fun

running into the street without

1 2 3 4 5 Seems irritable

looking

1 2 3 4 5 Moody

1 2 3 4 5 Blurts out answers to questions

1 2 3 4 5 Plays alone

before they have been

1 2 3 4 5 Cries easily

completed*

1 2 3 4 5 Seems tired*

1 2 3 4 5 Refuses to follow rules or do chores

1 2 3 4 5 Complaints of physical problems

1 2 3 4 5 Loses temper

(headaches, stomachaches)

1 2 3 4 5 Argues with parents or teachers

1 2 3 4 5 Worries

1 2 3 4 5 Blames others for own mistakes

1 2 3 4 5 Lacks confidence in abilities

1 2 3 4 5 Swears

1 2 3 4 5 Needs lots of reassurance

1 2 3 4 5 Deliberately does things to annoy

1 2 3 4 5 Needs to be perfect

other people

1 2 3 4 5 Seems fearful and anxious

1 2 3 4 5 Is angry or resentful

1 2 3 4 5 Seems shy or timid

1 2 3 4 5 Carries a grudge. Seems to have a

“a chip on their shoulder”

1 2 3 4 5 Easily embarrassed

1 2 3 4 5 Sensitive to criticism

1 2 3 4 5 Touchy, easily annoyed by others*

1 2 3 4 5 Bites fingernails*

1 2 3 4 5 Steals

1 2 3 4 5 Always on the go

1 2 3 4 5 Runs away overnight

1 2 3 4 5 Can’t sit still

1 2 3 4 5 Lies

1 2 3 4 5 Doesn’t seem to listen

1 2 3 4 5 Cuts school

1 2 3 4 5 Often fails to finish things

1 2 3 4 5 Is cruel to animals

1 2 3 4 5 Has poor concentration and

1 2 3 4 5 Destroys property

attention for school work

1 2 3 4 5 Gets into fights

1 2 3 4 5 Often fidgets with hands/feet

1 2 3 4 5 Has been physically cruel to

or squirms in seat

other people

1 2 3 4 5 Doesn’t seem sorry for hurting others

1 2 3 4 5 Easily distracted

1 2 3 4 5 Has a hard time playing quietly

1 2 3 4 5 Sets fires

1 2 3 4 5 Has broken into someone else’s house

1 2 3 4 5 Talks excessively

1 2 3 4 5 Often interrupts or “butts in” to

or car

others’ games

Child’s Name:_______________________________ Date:________________________

Completed By:_______________________________

Behavior Symptom Checklist

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