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Fields
Pediatric Symptom Checklist 17 (PSC-17)
Parent/Guardian Name
*
First Name
*
Last Name
*
Patient Name
*
First Name
*
Last Name
*
Patient Date of Birth
*
https://luriechildrens2.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Email Address
1. Feel sad
*
Never (0)
Sometimes (1)
Often (2)
2. Feel hopeless
*
Never (0)
Sometimes (1)
Often (2)
3. Feel down on themselves
*
Never (0)
Sometimes (1)
Often (2)
4. Worry a lot
*
Never (0)
Sometimes (1)
Often (2)
5. Seem to be having less fun
*
Never (0)
Sometimes (1)
Often (2)
6. Fidget, is unable to sit still
*
Never (0)
Sometimes (1)
Often (2)
7. Daydreams too much
*
Never (0)
Sometimes (1)
Often (2)
8. Distract easily
*
Never (0)
Sometimes (1)
Often (2)
9. Have trouble concentrating
*
Never (0)
Sometimes (1)
Often (2)
10. Act as if driven by a motor
*
Never (0)
Sometimes (1)
Often (2)
11. Fight with other children
*
Never (0)
Sometimes (1)
Often (2)
12. Not listen to rules
*
Never (0)
Sometimes (1)
Often (2)
13. Not understand people’s feelings
*
Never (0)
Sometimes (1)
Often (2)
14. Tease others
*
Never (0)
Sometimes (1)
Often (2)
15. Blame others for their troubles
*
Never (0)
Sometimes (1)
Often (2)
16. Refuse to share
*
Never (0)
Sometimes (1)
Often (2)
17. Take things that do not belong to them
*
Never (0)
Sometimes (1)
Often (2)
Full PSC-17
Internalizing (Mood and Anxiety)
Attention
Externalizing
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