Amen Child/teen General Symptom Checklist printable pdf download

Amen Child/teen General Symptom Checklist

Amen Child/Teen General Symptom Checklist

Name:___________________________________ Date: ____________

Parents please rate your child or teen on each of the symptoms listed below using the following scale. If possible, to

give us the most complete picture, have the child or teen rate him/herself as well. For young children it may not be

practical to have them fill out the questionnaire. Use your best judgment and do the best you can.

Unknown - Not

Never

Rarely

Occasionally

Frequently

Very Frequent

Applicable

Child

Parent

(_____) (_____) 1. depressed or sad mood

(_____) (_____) 2. not as much interest in things that are usually fun

(_____) (_____) 3. significant recent weight or appetite changes

(_____) (_____) 4. recurrent thoughts of death or suicide

(_____) (_____) 5. sleep changes, lack of sleep or marked increase in sleep

(_____) (_____) 6. low energy or feelings of tiredness

(_____) (_____) 7. feelings of being worthless, helpless, hopeless or guilty

(_____) (_____) 8. plays alone or appears socially withdrawn

(_____) (_____) 9. cries easily

(_____) (_____) 10. negative thinking

(_____) (_____) 11. periods of elevated, high or irritable mood

(_____) (_____) 12. periods of very high self esteem or big thinking

(_____) (_____) 13. periods of decreased need for sleep without feeling tired

(_____) (_____) 14. more talkative than usual or feel pressure to keep talking

(_____) (_____) 15. fast thoughts or frequent jumping from one subject to another

(_____) (_____) 16. easily distracted by irrelevant things

(_____) (_____) 17. marked increase in activity level

(_____) (_____) 18. cyclic periods of angry, mean or violent behavior

(_____) (_____) 19. periods of time when the child feels intensely anxious or nervous

(_____) (_____) 20. trouble breathing or has feelings of being smothered

(_____) (_____) 21. periods of feeling dizzy, faint or unsteady on your feet

(_____) (_____) 22. periods of heart pounding, fast heart rate or chest pain

Amen Child/teen General Symptom Checklist