Please read the questions and record your answers below.
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Has your child exhibited a lack of interest in their usual activities? Spends a lot of time alone in their room. Chores are forgotten or not done. Slowness in physical movements, uncooperative, bored, attention and concentration may be poor.
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Yes
No
Sometimes
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Change in appetite: May be evidenced by an increased interest in food, eating when not hungry, gorging. May be seen as disinterest in food; giving away lunches at school, avoiding family meals, complaining of having stomachache or already full.
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Yes
No
Sometimes
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Change in sleeping patterns: They may be falling asleep during any passive activity, watching TV, reading or listening to music. They may be unable to fall asleep, waking very early or often during the night, complaining of frequent bad dreams.
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Yes
No
Sometimes
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Loss of energy: Tired or restless behavior as evidenced by not carrying out chores, responsibilities, homework etc. Putting off doing everything, showing poor attention and concentration.
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Yes
No
Sometimes
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Blaming oneself inappropriately: Take criticism very hard, believe they are not as good as everyone else, cry very easily.
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Yes
No
Sometimes
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Negative feelings about self: Are not assertive with friends, peer relationships are poor, are very defensive in response to feeling worthless, are very critical or others, feel siblings are treated better than themselves.
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Yes
No
Sometimes
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Feelings of sadness, hopelessness and worry: They may look and feel sad and unhappy. They will give up easily, are disorganized because of an inability to concentrate or pay attention, tend to feel overwhelmed easily. Feel unable to do things they were able to do before. Have a constant need for emotional support from family and friends.
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Yes
No
Sometimes
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Morbid thoughts: They may seem preoccupied with death as evidenced by talking or writing about it, showing it in their artwork. They may seem overly involved in violence, terrorists or war actions. Death, dying and suicide may be themes they seek out in music, books, television. May isolate themselves in room playing music with morbid themes over and over.
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Yes
No
Sometimes
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Aggressive or negative behaviors: Quick to pick fights with peers, talks back, seems to not care about consequences at home or school.
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Yes
No
Sometimes
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Increased agitation: Short attention span, unable to sit still, doesn't complete projects, may speak or mutter under their breath.
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Yes
No
Sometimes
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Increased physical aches and pains: Headaches, stomachaches, sore muscles and other vague complaints are frequent. They seek constant attention. May be missing school frequently due to their vague physical complaints.
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Yes
No
Sometimes
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Declining academic performance: Work poorly done, work not turned in, they appear disorganized, work and desk are messy. Grades have dropped quickly from passing to failing.
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Yes
No
Sometimes
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Poor attention and concentration: Takes a long time to finish anything. Frequent guidance is necessary, waste time dawdling, frequently do nothing but watch T.V. or listening to music.
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Yes
No
Sometimes
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