For each item, please mark the circle for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems irrelevant. Pleasese give your answers on the basis of the child’s behaviour over the last six months. Fields marked with * are compulsory.Child's Name*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemale1. Considerate of other people's feelings*Not trueSomewhat trueCertainly true2. Restless, overactive, cannot stay still for long*Not trueSomewhat trueCertainly true3. Often complains of headaches, stomach-aches or sickness*Not trueSomewhat trueCertainly true4. Shares readily with other children (treats, toys, pencils etc.)*Not trueSomewhat trueCertainly true5. Often has temper tantrums or hot tempers*Not trueSomewhat trueCertainly true6. Rather solitary, tends to play alone*Not trueSomewhat trueCertainly true7. Generally obedient, usually does what adults request*Not trueSomewhat trueCertainly true8. Many worries, often seems worried*Not trueSomewhat trueCertainly true9. Helpful if someone is hurt, upset or feeling ill*Not trueSomewhat trueCertainly true10. Constantly fidgeting or squirming*Not trueSomewhat trueCertainly true11. Has at least one good friend*Not trueSomewhat trueCertainly true12. Often fights with other children or bullies them*Not trueSomewhat trueCertainly true13. Often unhappy, down-hearted or tearful*Not trueSomewhat trueCertainly true14. Generally liked by other children*Not trueSomewhat trueCertainly true15. Easily distracted, concentration wanders*Not trueSomewhat trueCertainly true16. Nervous or clingy in new situations, easily loses confidence*Not trueSomewhat trueCertainly true17. Kind to younger children*Not trueSomewhat trueCertainly true18. Often argumentative with adults*Not trueSomewhat trueCertainly true19. Picked on or bullied by other children*Not trueSomewhat trueCertainly true20. Often volunteers to help others (parents, teachers, other children)*Not trueSomewhat trueCertainly true21. Can stop and think things out before acting*Not trueSomewhat trueCertainly true22. Can be spiteful to others*Not trueSomewhat trueCertainly true23. Gets on better with adults than with other children*Not trueSomewhat trueCertainly true24. Many fears, easily scared*Not trueSomewhat trueCertainly true25. Sees tasks through to the end, good attention span*Not trueSomewhat trueCertainly trueDo you have any other comments or concerns?Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?*NoYes - minor difficultiesYes - definite difficultiesYes - severe difficultiesIf you have answered "Yes", please answer the following questions about these difficulties:How long have these difficulties been present?Less than a month1 - 5 months6 - 12 monthsOver a yearDo the difficulties upset or distress your child?Not at allOnly a littleQuiet a lotA great dealDo the difficulties interfere with your child's everyday life in the following areas?HOME LIFENot at allOnly a littleQuiet a lotA great dealFRIENDSHIPSNot at allOnly a littleQuiet a lotA great dealLEARNINGNot at allOnly a littleQuiet a lotA great dealLEISURE ACTIVITIESNot at allOnly a littleQuiet a lotA great dealDo the difficulties put a burden on you or the family as a whole?Not at allOnly a littleQuiet a lotA great dealPARENT's NAME*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Antispam code
