Pediatric Assessment Form Are you the patient's parent?(Required) Yes No, I am the guardian signing up on behalf of the patient Date(Required) MM slash DD slash YYYY Email Patient Name(Required) First Last Never = Not at all | Sometimes = Once or twice | Often = More than the usual Complains of aches and pains(Required) Never Sometimes Often Tires easily, has little energy(Required) Never Sometimes Often Spends more time alone(Required) Never Sometimes Often Fidgety, unable to sit still(Required) Never Sometimes Often Has trouble with teacher(Required) Never Sometimes Often Less interested in school(Required) Never Sometimes Often Acts as if driven by a motor(Required) Never Sometimes Often Daydreams too much(Required) Never Sometimes Often Distracted easily(Required) Never Sometimes Often Is afraid of new situations(Required) Never Sometimes Often Feels sad, unhappy(Required) Never Sometimes Often Is irritable, angry(Required) Never Sometimes Often Feels hopeless(Required) Never Sometimes Often Has trouble concentrating(Required) Never Sometimes Often Less interested in friends(Required) Never Sometimes Often Fights with other children(Required) Never Sometimes Often Absent from school(Required) Never Sometimes Often School grades dropping(Required) Never Sometimes Often Is down on him or herself(Required) Never Sometimes Often Visits the doctor with doctor finding nothing wrong(Required) Never Sometimes Often Has trouble sleeping(Required) Never Sometimes Often Worries a lot(Required) Never Sometimes Often Wants to be with you more than before(Required) Never Sometimes Often Wants to be with you more than before(Required) Never Sometimes Often Feels he or she is bad(Required) Never Sometimes Often Takes unnecessary risks(Required) Never Sometimes Often Gets hurt frequently(Required) Never Sometimes Often Seems to be having less fun(Required) Never Sometimes Often Acts younger than children his or her age(Required) Never Sometimes Often Does not listen to rules(Required) Never Sometimes Often Does not show feelings(Required) Never Sometimes Often Does not understand other people’s feelings(Required) Never Sometimes Often Teases others(Required) Never Sometimes Often Blames others for his or her troubles(Required) Never Sometimes Often Takes things that do not belong to him or her(Required) Never Sometimes Often Refuses to share(Required) Never Sometimes Often Does your child have any emotional or behavioral problems for which she or he needs help?(Required) Yes No Are there any services that you would like your child to receive for these problems?(Required) Yes No If yes, what services?(Required) Better days are ahead! Let's work together to create change. Start Now
