SYMPTOM CHECK-LIST
PHYSICAL COMPLAINTS
Giddiness
Abdominal Pain
Headache
Fits
Others………...
BEHAVIOR PROBLEMS
Nervous Timid1
Fidgety2
Clumsy3
Aggressive
Overactive
Stubborn
Demanding
Disobedient
Bullying4 others
Getting bullied
Anti-social
Loitering5
Seclusive6
Inattentive
Distractible7
Impulsive10
Motor retardation11
Temper tantrums12
SLEEP DISTURBANCES
Initial insomnia
Terminal insomnia
Total insomnia
Afraid to go to sleep
Disturbed sleep
Excessive reported sleep
Nightmares & night terrors
Somnambulism13
APPETITE
Normal
Food fads14
Pica
Others……….
PROBLEMS OF ELIMINATION
Constipation
Diarrhea
Enuresis
Dribbling15
Encopresis
SCHOOLING
Irregular to school
Scholastic backwardness
Below average intelligence
Truancy –home/school
Abnormal peer/ group adjustment
Fear of going to school
READING DIFFICULTIES
In own language
In foreign language
Spelling mistakes
SPEECH & LANGUAGE DIFFICULTIES
Stammering16
Lisping17
Lalling
Mutism
Under talkative
Pronominal reversal
Echolalia
Immature grammatical structure
Personalized language
Inability to comprehend18 spoken language
SEXUAL PRACTICES
Masturbation
Homosexuality
Transvestism
Others……….
SITUATION SPECIFIC ANXIETY
Being in a group
Being left alone
Vehicles
Animals
Undressing crowds
New people
Others……….
NEUROTIC SYMPTOMS
Tics
Mannerisms
Thumb sucking
Nail biting
Hypochondria19
Cruelty to animals
Hysterical20 symptoms (fits, possession, fugue, amnesia, unconsciousness, motor symptoms, sensory symptoms, visceral symptoms)
Obsessions and compulsions
PSYCHOTIC SYMPTOMS
Hallucinations
Delusions
Autism
Silly smile
Neglect of personal hygiene
Speech block
Withdrawal
Increased Socialization
Bizarre movements
Inability to form relationships
Preference to inanimate objects
Irrelevant talk
MOOD
Elated
Depressed
Miserable
Irritable
Worrying
Anxious
Panicky
Fearful
Hostile
Suspicious
SUICIDAL RUMINATIONS AND ATTEMPTS
Ideation
Threats
Attempts
OTHERS…………………………………………………………………............
...........…………………………………………………………………………………………………
1. Timid: Lacking courage or confidence.
2. Fidgety: Make small movements through nervousness/impatience.
3. Clumsy: Awkward (hard to do/deal with), (inconvenient) in movement or performance.
4. Bully: A person who intimidates (frighten, esp. into doing something) weaker people.
5. Loiter: Stand around idly (avoiding work; lazy; spend time wandering, doing nothing).
6. Seclusion: Privacy.
7. Distraction: Mental agitation
8. Distraught: Very worried and upset.
9. Distress: extreme anxiety, pain or hardship.
10. Impulse: a sudden urge to do something/ a driving force.
11. Retardation: holding back the development or progress of.
12. Tantrum: an uncontrolled outburst of anger and frustration.
13. Somnambulism: sleep walking.
14. Fads: Craze
15. Dribble : fall slowly in drops or a thin stream
16. Stammer: speak with involuntary pauses and repetitions of the first letters of words.
17. Lisp: a speech defect in which‘s’ and ‘z’ are pronounced like ‘th’.
18. Comprehend: understand.
19. Hypochondria: Constant and excessive anxiety about one’s health.
20. Hysterical: extreme/uncontrollable emotion/excitement.
21. Spasm: a sudden involuntary contraction of a muscle. A sudden spell of an activity/sensation.
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