Pediatric Symptom Checklist (Psc) Template
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1(For the office of Angela P. Wu, LCSW)
DATE ___________________________________
CHILD’S NAME _______________________________
COMPLETED BY _________________________
RELATIONSHIP TO CHILD ________________
D.O.B. ________________________________________
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
(0)
(1)
(2)
1.___________
_____________
___________
1. Complains of aches and pains
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/he needs help?
__No
__Yes
Are there any services that you would like your child to receive for these problems?
__No
__Yes
If yes, what type of services? ______________________________________________________________________________
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