ATTENTION When symptoms began (date) MOOD When symptoms began (date) Careless mistakes Poor attention span Doesn’t listen Doesn’t finish tasks Problems organizing Avoids tasks requiring concentration Loses needed items Easily distracted Trouble remembering/forgetful Fidgets, squirms Leaves seat when required to sit On the go, seems driven Runs, climbs excessively/restless Talks all the time Problems waiting turn Interrupts Weight changes/appetite changes Y Energy level changes Y Sleep disturbances Y Difficulty concentrating Y Crying spells Y Loss of interest/pleasure Y Hopeless feelings Y Guilty feelings Y Isolates self Y Low self-esteem/self-hate Y Gives things away Y Wishes to be dead Y Injures self Y Thinks about death/violence often Y Rage outbursts Y Bizarre behaviors, hallucinations Y Rapid, hard to follow speech/thoughts Y Thinks s/he is the smartest, best person in the world Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y S S S S S S S S S S S S S S S S N N N N N N N N N N N N N N N N OPPOSITIONAL BEHAVIORS When symptoms began (date) ANXIETY/W ORRY When symptoms began(date) Touchy, easily annoyed Argues Defiant Angry Tantrums Bothers others deliberately Spiteful/mean Blames others for own mistakes Worries something terrible will happen to self or important adults Frequently refuses or is reluctant to go somewhere fear of separation Avoids being alone Nightmares about separation Physical complaints about the time of separation transition Worries about parent(s) leaving Fearfulness of new situations, people or objects Engages in repeated behaviors (counting, cleaning organizing, hand washing, etc.) Excessive worry about everyday things Fear/excessive worry about social situations Y Y Y Y Y Y Y Y S S S S S S S S N N N N N N N N CONDUCT When symptoms began (date) Bullies/threatens others Starts fights Used a weapon Physically cruel to people/animals Forcibly stolen
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