Patient Symptom Checklist Page 3
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4Mood Disorder Symptoms
Yes
No
Comments/Additional thoughts
Complains of being bored
Complains of a lot of ideas at one time
Has periods of excessive, rapid speech
Displays rapid, abrupt mood swings
Displays periods of hyperactivity
Has irritable mood states
Has excessively silly, giddy mood states
Has exaggerated ideas about self or abilities
Explosive temper tantrums or rages
Has destroyed property intentionally
Curses viciously in anger
Has physically assaulted another person
Is fascinated with blood and gore
Educational History: Grade Level__________Grades Failed______ Currently Failing________________
Special Education;
Yes____ No_______ Reason___________________________________________
504 Identified Needs:__________________________________Reported IQ_______________________
Suspensions: Yes_____No______Reason____________________________________________________
Alternative School Placement: Yes___No___Dates____________________________________________
Reason________________________________________________________________________________
ABUSE HISTORY
TYPE
Child’s Age
Abused By
CPS Report
Made
Emotional
Neglect
Physical
Sexual
Domestic Violence
Yes
No
Comments/ Additional thoughts
Other Issues
Bedwetting, soiling self
Sexualized behaviors or sexually bizarre drawings
Sexually promiscuous, seductive or provocative
dress/behavior
Unusual preoccupation with sexual acts or language
Sexual acting out play with other children or animals
Internet usage excessive; My Space, etc
Reports haring voices or seeing things
Bizarre thoughts or behaviors
PATIENT NAME
THE EXCEL CENTER
PATIENT SYMPTOM PARENT REPORT
12/12 pdexcelforms
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Parent category: Life