Pediatric Symptom Checklist Template
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1BRIGHT FUTURES
TOOL FOR PROFESSIONALS
Pediatric Symptom Checklist (PSC)
Emotional and physical health go together in children. Because parents are often the first to notice a problem with their
child’s behavior, emotions, or learning, you may help your child get the best care possible by answering these questions.
Please indicate which statement best describes your child.
Please mark under the heading that best describes your child:
Never
Sometimes
Often
1.
Complains of aches and pains
1
_______
_______
_______
2.
Spends more time alone
2
_______
_______
_______
3.
Tires easily, has little energy
3
_______
_______
_______
4.
Fidgety, unable to sit still
4
_______
_______
_______
5.
Has trouble with teacher
5
_______
_______
_______
6.
Less interested in school
6
_______
_______
_______
7.
Acts as if driven by a motor
7
_______
_______
_______
8.
Daydreams too much
8
_______
_______
_______
9.
Distracted easily
9
_______
_______
_______
10. Is afraid of new situations
10
_______
_______
_______
11. Feels sad, unhappy
11
_______
_______
_______
12. Is irritable, angry
12
_______
_______
_______
13. Feels hopeless
13
_______
_______
_______
14. Has trouble concentrating
14
_______
_______
_______
15. Less interested in friends
15
_______
_______
_______
16. Fights with other children
16
_______
_______
_______
17. Absent from school
17
_______
_______
_______
18. School grades dropping
18
_______
_______
_______
19. Is down on him or herself
19
_______
_______
_______
20. Visits the doctor with doctor finding nothing wrong
20
_______
_______
_______
21. Has trouble sleeping
21
_______
_______
_______
22. Worries a lot
22
_______
_______
_______
23. Wants to be with you more than before
23
_______
_______
_______
24. Feels he or she is bad
24
_______
_______
_______
25. Takes unnecessary risks
25
_______
_______
_______
26. Gets hurt frequently
26
_______
_______
_______
27. Seems to be having less fun
27
_______
_______
_______
28. Acts younger than children his or her age
28
_______
_______
_______
29. Does not listen to rules
29
_______
_______
_______
30. Does not show feelings
30
_______
_______
_______
31. Does not understand other people’s feelings
31
_______
_______
_______
32. Teases others
32
_______
_______
_______
33. Blames others for his or her troubles
33
_______
_______
_______
34. Takes things that do not belong to him or her
34
_______
_______
_______
35. Refuses to share
35
_______
_______
_______
Total score ______________
Does your child have any emotional or behavioral problems for which she or he needs help?
( ) N
( ) Y
Are there any services that you would like your child to receive for these problems?
( ) N
( ) Y
If yes, what services?______________________________________________________________________________________________
17
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