Do you currently receive counseling or behavioral health services? If yes, where?
Yes No
Are you interested in talking with someone about your child’s behavior or development?
Yes No
For Office Use Only
To Score
1. Score the items
2. Find the summed total
Any summed score of 9 or more means that families might like to talk about how to
learn more about their young child.
Patient Identifier
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST
Recommended 18 month, 0 days to 65 months, 31 days
Your Name:
Relationship to the child:
These questions are about your child's behavior. Think about what you would expect of other children the
same age, and tell us how much each statement applies to your child.
Please mark under the heading
that best fits you
Not at all
Somewhat
Very much
Does your child…
Seem nervous or afraid?
0 1 2
Seem sad or unhappy?
0 1 2
Get upset if things are not done in a certain
way?
0 1 2
Have a hard time with change?
0 1 2
Have trouble playing with other children?
0
1
2
Break things on purpose?
0 1 2
Fight with other children?
0
1
2
Have a hard time calming down?
0 1 2
Have trouble staying with one activity?
0
1
2
Is your child…
Aggressive?
0 1 2
Fidgety or unable to sit still?
0
1
2
Angry?
0 1 2
Is it hard to…
Take your child out in public?
0
1
2
Comfort your child?
0 1 2
Know what your child needs?
0
1
2
Keep your child on a schedule or routine?
0 1 2
Get your child to obey you?
0
1
2
Total Sum (across Columns)
_______
