Symptom Checklist Page 2

Evidenced By

(For Office Use Only)

Has bad dreams over and over

Becomes upset when reminded of something bad or scary

Stays away from or will not talk about things that remind

him/her of something bad or scary that happened

Jumpy or scared easily

Seems to do things over and over without good reason

e.g. washing hands, touching things, checking locked doors

Has problems paying attention

Is easily distracted

Is often forgetful

Often fidgets with hands or feet

Lots of physical movement

Talks a lot

Behavioral problems in school

Often acts without thinking

Often loses temper

Often argues

Will not follow rules or directions

Bullies, threatens or intimidates others

Starts physical fights

Destroys property

Steals

Lies

Symptom Check List

Page 2 of 4

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Parent category: Life