| Please place a mark in the appropriate column
for each symptom as it pertains to your child. Please give
a brief description of your child's behavior regarding each
of the symptoms checked as moderate or severe. This form is
for personal reference only. |
|
NONE |
MILD |
MODERATE |
SEVERE |
| 1. Lack of impulse control |
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| 2. Self destructive behaviors |
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| 3. Intense displays of anger (rage) |
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| 4. Destruction of property |
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| 5. Preoccupation with fire, gore, or evil |
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| 6. Aggression toward others |
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| 7. Inappropriate sexual conduct and attitudes |
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| 8. Cruelty to animals |
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| 9. Frequently defies rules (oppositional) |
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| 10. Cannot tolerate limits and external control |
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| 11. Victimizes others (perpetrator, bully) |
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| 12. Exploitive (manipulative, controlling) |
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| 13. Bossy |
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| 14. Consistently irresponsible |
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| 15. Inappropriately demanding and clingy |
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| 16. Marked mood changes |
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| 17. Stealing |
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| 18. Deceitful (lying, conning) |
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| 19. Hoarding |
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| 20. Sleep disturbance |
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| 21. Enuresis (wets self) |
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| 22. Encopresis (soils self) |
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| 23. Hyperactivity |
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| 24. Abnormal eating habits |
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| 25. Persistent nonsense questions and incessant chatter |
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| 26. Lack of cause and effect thinking |
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| 27. Lack of remorse and conscience |
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| 28. Learning disorders |
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| 29. Language disorders |
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| 30. Perceives self as victim (helpless) |
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| 31. Grandiose sense of self-importance |
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| 32. Perceives others as unsafe, dangerous |
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| 33. Not affectionate on parents' terms |
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| 34. Frequently depressed, sad |
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| 35. Feelings of hopelessness |
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| 36. Inappropriate emotional response |
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| 37. Superficially engaging and charming |
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| 38. Lack of eye contact on parents terms |
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| 39. Indiscriminately affection with strangers |
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| 40. Lack of long-term friends |
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| 41. Unstable peer relationships |
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| 42. Blames others for own mistakes or problems |
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| 43. Victimized by others |
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| 44. Lacks trust of caretaking or control by others |
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| 45. Accident prone |
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46. Child is adopted (check one)
Yes___ No___ |
47. Child experienced separations from birth mother
during first 2 years
Yes___ No___ |
48. Child experienced unrelieved pain during first
2 years
Yes___ No___ |
|
