Pediatric Symptom Checklist 17 (PSC-17)

Child’s Name: ___________________________________________ Date of Birth: _______________________

Filled out by: ____________________________________________ Today’s Date: ______________________

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 indicate which statement best describes your child.

Please mark under the heading that best describes your child: Never Sometimes Often

 Fidgety, unable to sit still 0 1 2

 Feels sad, unhappy 0 1 2

 Daydreams too much 0 1 2

 Refuses to share 0 1 2

 Does not understand other people’s feelings 0 1 2

 Feels hopeless 0 1 2

 Has trouble concentrating 0 1 2

 Fights with other children 0 1 2

 Is down on him or her self 0 1 2

 Blames others for his or her troubles 0 1 2

 Seems to have less fun 0 1 2

 Does not listen to rules 0 1 2

 Acts as if driven by a motor 0 1 2

 Teases others 0 1 2

 Worries a lot 0 1 2

 Takes things that do not belong to him or her 0 1 2

 Distracted easily 0 1 2

Total  ______ Total  ______ Total  _______  +  +  ______