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Pediatric Symptom Checklist
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Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’s behavior, emotions or learning, you may help your child get the best care possible by answering these questions. Please mark under the heading that best fits your child.

Complains of aches/pains *
Spends more time alone *
Tires easily, has little energy *
Fidgety, unable to sit still *
Has trouble with a teacher *
Less interested in school *
Acts as if driven by a motor *
Daydreams too much *
Distracted easily *
Is afraid of new situations *
Feels sad, unhappy *
Is irritable, angry *
Feels hopeless *
Has trouble concentrating *
Less interest in friends *
Fights with others *
Absent from school *
School grades dropping *
Is down on him or herself *
Visits doctor with doctor finding nothing wrong *
Has trouble sleeping *
Worries a lot *
Wants to be with you more than before *
Feels he or she is bad *
Takes unnecessary risks *
Gets hurt frequently *
Seems to be having less fun *
Acts younger than children his or her age *
Does not listen to rules *
Does not show feelings *
Does not understand other people’s feelings *
Teases others *
Blames others for his or her troubles *
Takes things that do not belong to him or her *
Refuses to share *
0.00
Does your child have any emotional or behavioral problems for which she/he needs help?
Are there any services that you would like your child to receive for these problems?
If yes, what services?
Child's Name *
Date of Birth *
Parent Name *
Phone Number
Email Address *
Street Address
City
State
ZIP Code

By clicking “Submit”, you are authorizing the information you provided to be released to your local Help Me Grow.

I agree to allow Help Me Grow Florida to enter this data into a secure database, contact me with the results of this screening, and provide me with any relevant resources.

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