PsyCare

The following assessments should be completed by the patient if they are between the ages of 11 and 16:

PEDIATRIC SYMPTOM CHECKLIST- YOUTH REPORT

Please mark the option that best fits you:

1. Complain of aches and pains 2. Spend more time alone 3. Tire easily, has little energy 4. Fidgety, unable to sit still 5. Have trouble with teacher 6. Less interested in school 7. Act as if driven by a motor 8. Daydream too much 9. Distract easily 10. Are afraid of new situations 11. Feel sad, unhappy 12. Are irritable, angry 13. Feel hopeless 14. Have trouble concentrating 15. Less interested in friends 16. Fight with other children 17. Absent from school 18. School grades dropping 19. Down on yourself 20. Visit the doctor with doctor finding nothing wrong 21. Have trouble sleeping 22. Worry a lot 23. Want to be with parent more than before 24. Feel that you are bad 25. Take unnecessary risks 26. Get hurt frequently 27. Seem to be having less fun 28. Act younger than children your age 29. Do not listen to rules 30. Do not show feelings 31. Do not understand other people?s feelings 32. Tease others 33. Blame others for his or her troubles 34. Take things that do not belong to you 35. Refuse to share

COLUMBIA IMPAIRMENT SCALE

Please select the number that you think best describes the child or youth?s situation:

In general, how much of a problem do you think you have with:

1) getting into trouble? 2) getting along with your mother/mother figure). 3) getting along with your father/father figure). 4) feeling unhappy or sad?

How much of a problem would you have:

5) with your behavior at school? (or at your job) 6) with having fun? 7) getting along with adults (other than your mother and/or your father)?

How much of a problem do you have:

8) with feeling nervous or afraid? 9) getting along with your sister(s) and/or brother(s)? 10) getting along with other kids your age?

How much of a problem would you say you have:

11) getting involved in activities like sports or hobbies? 12) with your school work (doing your job)? 13) with your behavior at home?