Child's Name
Gender
Age
Birthdate
Relationship to Child
If other, specify
How well do you know the child?
Have known the child for (months/years)
Instructions: During the past 6 months, how often has each of the following behaviors been a problem?
Never
Sometimes Often
Never
Sometimes Often
Never
Sometimes Often
1. Overreacts to small problems
2. When given two things to do, remembers only the first or last
3. Is unaware of how his/her behavior affects or bothers others
4. When instructed to clean up, puts things away in a disorganized, random way
5. Becomes upset with new situations
6. Has explosive, angry outburt
7. Has trouble carrying out the actions needed to complete tasks (such as trying
one puzzle piece at a time, cleaning up to earn a reward)
8. Does not stop laughing at funny things or events when others stop
9. Needs to be told to begin a task even when willing to do it
10. Has trouble adjusting to new people (such as babysitter, teacher, friend, or
day care worker)
11. Becomes upset too easily
12. Has trouble concentrating on games, puzzles, or play activities
13. Has to be more closely supervised than similar playmates
14. When sent to get soemthing, forgets what he/she is supposed to get
15. Is upset by a change in plans or routine (for example, order of daily activities,
adding last minute errands to schedule, change in driving routine to store)
16. Has outbursts for little reason
17. Repeats the same mistake over and over even after help is given
18. Acts wilder or sillier than others in group (i.e. birthday parties, play groups)
19. Cannot find clothes, shoes, toys or books even when he/she has been given
specific instructions
20. Takes a long time to feel comfortable in new places or situations (such as
visiting distant relatives or new friends)
21. Mood changes frequently
22. Makes silly mistakes on things he/she can do
23. Is fidgety, restless, or squirmy
24. Has trouble following established routines for sleeping, eating, or play activities
25. Is bothered by loud noises, bright lights, or certain smells
26. Small events trigger big reactions
Never
Sometimes Often
Never
Sometimes Often
Never
Sometimes Often
27. Has trouble with activities or tasks that have more than one step
28. Is impulsive
29. Has trouble thinking of a different way to solve a problem or complete an
activity when stuck
30. Is disturbed by changes in the environment (such as new furniture, things in
room moved around, or new clothes)
31. Angry or tearful outbursts are intense but end suddenly
32. Needs help from an adult to stay on task
33. Does not notice when his/her behavior causes negative reactions
34. Leaves messes that others have to clean up even after instructions
35. Has trouble changing activities
36. Reacts more strongly to situations than other children
37. Forgets what he/she is doing in middle of an activity
38. Does not realize that certain actions bother others
39. Gets caught up in the small details of a task or situation and misses the main
idea
40. Has trouble "joining in" at unfamiliar social events (such as birthday parties,
picnics, holiday gatherings.
41. Is easily overwhelmed or overstimulated by typical daily activities
42. Has trouble finishing tasks (such as games, puzzles, pretend play activities)
43. Gets out of control more than playmates
44. Cannot find things in room or play area even when given specific instructions
45. Resists change of routine, foods, places, etc.
46. After having a problem, will stay disappointed for a long time
47. Cannot stay on topic when talking
48. Talks or plays too loudly
49. Does not complete tasks even after given directions
50. Acts overwhelmed or overstimulated in crowded, busy situations (such as lots
of noise, activity, or people)
51. Has trouble getting started on activities or tasks even after instructed
52. Acts too wild or out of control
53. Does not try as hard as his/her ability on activities
54. Has trouble putting the brakes on his/her actions even after being asked
55. Unable to finish describing an event, person, or story
56. Completes tasks or activities too quickly
57. Is unaware when he/she does well and not well
58. Gets sidetracked during activities
Never
Sometimes Often
59. Has trouble remembering something, even after a brief period of time
60. Becomes too silly
61. Has a short attention span
62. Plays carelessly or recklessly in situations where he/she could be hurt (such
as playground, swimming pool)
63. Is unaware when he/she performs a task right or wrong
Instructions: Read each item carefully, then mark how well it describes your child or how frequently
it has happened in the past month.
0 = In the past month, this was not true at all about my child. It never (or seldom) happened.
1 = In the past month, this was just a little true about my child. It happened occasionally.
2 = In the past month, this was pretty much true about my child. It happened often (or quite a bit)
3 = In the past month, this was very much true about my child. It happened very often (very frequently)
Please select one answer for each item. It is important to respond to every item. For items that you find difficult to
answer, please give your best guess.
1. Forgets to turn in completed work.
2. Is perfect in every way.
3. Is one of the last to be picked for teams or games.
4. Does not know how to make friends.
5. Runs or climbs when he/she is not supposed to.
6. Cannot grasp arithmetic.
7. Is difficult to please or amuse.
8. Is hard to motivate (even with rewards like candy or money).
9. Acts as if driven by a motor.
10. Starts fights with others on purpose.
11. Is happy, cheerful, and has a positive attitude.
12. Doesn't pay attention to details; makes careless mistakes.
13. Has trouble keeping friends.
14. Bullies, threatens, or scares others.
15. Loses things (for example, schoolwork, pencils, books, tools, or toys).
16. Tells lies to hurt other people.
17. I cannot figure out what makes him/her happy.
18. Threatens to hurt others.
19. Has trouble with reading.
20. Is angry and resentful.
21. Tells the truth; doesn't even tell "little white lies".
22. Has trouble organizing tasks or activities.
23. Is fun to be around.
24. Spelling is poor.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
25. Is patient and content, even when waiting in a long line.
26. Has no friends.
27. Does not understand what he/she reads.
28. Behaves like an angel.
29. Does not get invited to play or go out with others.
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
32. Do you have any other concerns about your child?
33. What strengths or skills does your child have?
Instructions: Indicate how frequently each behavior occurs.
Never
1. Shares toys or possessions with other children.
2. Speaks in short phrases that are hard to understand.
3. Gets colds.
4. Compliments others.
5. Acts without thinking.
6. Eats things that are not food.
7. Seems unaware of others.
8. Gets sick.
9. Sleeps with parents.
10. Break other children's things.
11. Misses school or daycare because of sickness.
12. Pouts.
13. Provides own telephone number when asked.
14. Says, "Nobody likes me."
15. Seeks revenge on others.
16. Congratulates others when good things happen to them.
17. Worries about what parents think.
18. Argues when denied own way.
19. Worries about parents.
20. Complains about being teased.
Sometimes
Often
Always
Never
Sometimes
Often
Always
Never
Sometimes
Often
Always
21. Has headaches.
22. Avoids other children.
23. Is fearful.
24. Recovers quickly after a setback.
25. Provides full name when asked.
26. Vomits.
27. Begins conversations appropriately.
28. Has poor self-control.
29. Listens carefully.
30. Says, "I'm afraid I will make a mistake."
31. Babbles to self.
32. Is shy with other children.
33. Complains about health.
34. Decides what clothing to wear without help.
35. Calls other children names.
36. Complains about being cold.
37. Communicates clearly.
38. Is sad.
39. Interrupts others when they are speaking.
40. Annoys others on purpose.
41. Offers to help other children.
42. Gets very upset when things are lost.
43. Whines.
44. Worries about what other children think.
45. Cries easily.
46. Has ear infections.
47. Is too serious.
Never
Sometimes
Often
Always
Never
Sometimes
Often
Always
48. Provides home address when asked.
49. Needs help tying shoes.
50. Says, "please" and "thank you."
51. Needs too much supervision.
52. Pays attention.
53. Worries about things that cannot be changed.
54. Bangs head.
55. Shows fear of strangers.
56. Makes frequent visits to the doctor.
57. Needs help putting on clothes.
58. Hits other children.
59. Tries new things.
60. Stares blankly.
61. Says all letters of the alphabet when asked.
62. Acts strangely.
63. Encourages others to do their best.
64. Worries.
65. Loses temper too easily.
66. Has a hearing problem.
67. Listens to directions.
68. Has fevers.
69. Is shy with adults.
70. Is cruel to animals.
71. Is easily soothed when angry.
72. Answers telephone properly.
73. Needs help using zippers.
74. Politely asks for help.
Never
Sometimes
Often
Always
Never
Sometimes
Often
Always
75. Fiddles with things while at meals.
76. Is easily distracted.
77. Worries about making mistakes.
78. Acts confused.
79. Readily starts up conversations with new people.
80. Has stomach problems.
81. Fails to wash hands when needed.
82. Teases others.
83. Shows feelings that do not fit the situation.
84. Responds appropriately when asked a question.
85. Says things that make no sense.
86. Needs help bathing self.
87. Uses appropriate table manners.
88. Tries to be perfect.
89. Is clear when telling people about personal experiences.
90. Refuses to join group activities.
91. Falls down.
92. Pays attention when being spoken to.
93. Complains of pain.
94. Clings to parents in strange surroundings.
95. Interrupts parents when they are talking on the phone.
96. Has seizures.
97. Is able to describe feelings accurately.
98. Has trouble fastening buttons on clothing.
99. Volunteers to help with things.
100. Is easily annoyed by others.
101. Says, "I'm not very good at this."
Never
Sometimes
Often
Always
Never
Sometimes
Often
Always
102. Chews clothing or blankets.
103. Wets bed.
104. Has sore throats.
105. Has trouble eating with a fork.
106. Disrupts the play of other children.
107. Does strange things.
108. Sets fires.
109. Is negative about things.
110. Has toileting accidents.
111. Needs to be reminded to brush teeth.
112. Has eye problems.
113. Is nervous.
114. Is unclear when presenting ideas.
115. Quickly joins group activities.