Very True	Somewhat or Sometimes True	Not True
1	Your son/daughter often complains about some physical discomfort (for example: a headache, stomach ache, etc.)	□	□	□
2	He is excessively worried about illnesses and/or that he will get ill	□	□	□
3	He finds it difficult to fall asleep or says he does not sleep well	□	□	□
4	His sleep is disturbed by nightmares or waking up during the night	□	□	□
5	He appears tense and/or anxious	□	□	□
6	He tends to worry about everything	□	□	□
7	He worries about school too much	□	□	□
8	It is hard for him to be separated or far from his parents	□	□	□
9	He is excessively shy	□	□	□
10	He is usually embarrassed around strangers or people he does not know very well	□	□	□
11	He is excessively afraid of something (e.g. the dark, being alone, insects, thieves) Specify what he is afraid of	□	□	□
12	He is excessively afraid of dirt, so he has to wash continually	□	□	□
13	There are repetitive actions or “rituals” that he frequently repeats and he says he cannot help doing them, If yes, describe which ones	□	□	□
14	He has an obsessive need for things to be in a precise order	□	□	□
15	He is obsessed by unpleasant thoughts and cannot free himself from them	□	□	□
16	He is very afraid of making mistakes	□	□	□
17	It is hard for him to make decisions, even about unimportant things	□	□	□
18	Has he ever been involved in or witnessed particularly stressful events, after which his behaviour changed in some way? If true, indicate what behavioural changes occurred after the event	□	□	□
19	He cries for no reason or about unimportant things	□	□	□
20	He often seems sad	□	□	□
21	He is often in a black mood (“depressed”)	□	□	□
22	He says or shows that he is not happy	□	□	□
23	He shows no interest, not even in pleasant things	□	□	□
24	He feels inferior to others; he has low self-esteem	□	□	□
25	He is often tired or listless; everything exhausts him	□	□	□
26	He blames himself too much	□	□	□
27	He has sometimes said he does not want to live any longer	□	□	□
28	He has hurt himself or tried to hurt himself	□	□	□
29	He is very irritable	□	□	□
30	He often gets angry, even about unimportant things	□	□	□
31	He has frequent mood changes	□	□	□
32	He is quick-tempered and has fits of anger	□	□	□
33	He does not obey and it is difficult to make him obey	□	□	□
34	He does not follow the rules	□	□	□
35	He often tells lies or cheats	□	□	□
36	He is domineering and always wants to assert himself	□	□	□
37	He quarrels frequently	□	□	□
38	He bothers and intentionally annoys others	□	□	□
39	He often hits people	□	□	□
40	He destroys things	□	□	□
41	He is or has been cruel to animals or people	□	□	□
42	He has committed petty theft	□	□	□
43	He is impulsive and acts before thinking	□	□	□
44	He tends not to take turns when he is playing	□	□	□
45	He interrupts, disturbing games or others’ conversations	□	□	□
46	He is always moving around and cannot stay still	□	□	□
47	He cannot sit down for a long time but has to get up	□	□	□
48	He runs and jumps everywhere in an exaggerated way	□	□	□
49	He has trouble concentrating while doing his homework	□	□	□
50	He has trouble paying attention to something for a long period	□	□	□
51	He gets tired very quickly even when he is playing	□	□	□
52	He feels persecuted	□	□	□
53	He is overly suspicious	□	□	□
54	Sometimes he has strange ideas	□	□	□
55	Sometimes he says he sees or hears things that are not there	□	□	□
56	He has difficulty in relating to and interacting with others	□	□	□
57	He cannot make real friends or does not seem interested in doing so	□	□	□
58	He does not play willingly with his peers	□	□	□
59	He does not seem to express emotions using appropriate facial expressions	□	□	□
60	His behaviour is "strange", unlike that of his peers	□	□	□
61	He asks inappropriate questions, like overly-personal questions to strangers at inopportune times	□	□	□
62	He sometimes wets the bed	□	□	□
63	He sometimes dirties his pants during the day	□	□	□
64	He stuffs himself with food	□	□	□
65	He keeps to a strict diet (not prescribed by a doctor or dietician)	□	□	□
66	He feels too fat or says that parts of his body are too fat	□	□	□
67	He has recently lost a lot of weight	□	□	□
68	He appears to be overly interested in sex	□	□	□
69	He shows he would like to be of the opposite sex	□	□	□
70	He smokes	□	□	□
71	He drinks alcohol	□	□	□
72	He uses drugs (smokes hashish or other dangerous substances)	□	□	□
73	He does not do well at school	□	□	□
74	He has recently done much worse at school	□	□	□
75	His classmates or other children make fun of him, threaten or mistreat him	□	□	□

List the numbers of the questions whose meaning was unclear:...................... ................ ................ ................ ................ ............................................................

Does your child exhibit behaviour which seems to you different from that of his peers? Give details. ...................................................................................................................... ................ ................ ................ ................ ................................................................. ...........................................................................................................................................................................................................................................................

Does your child exhibit behaviour which worries you? Give details.................................................................. ................ ................ ................ ................ .......... ........................................................................................................................................................................................................................................................... .......................................................... ........................................................ ........................................................ ...............................................................................

If there are episodes that worry you, it is better not to ignore them. Problems can usually be solved if they are faced adequately and in time. Problems that are ignored may later be difficult to solve.