As a child I was (or had):
1. Active, restless, always on the go Not at all or very slightly Mildlyof Moderately Quite a bit Very much
2. Afraid of things Not at all or very slightly Mildly Moderately Quite a bit Very much
3. Concentration problems, easily distracted Not at all or very slightly Mildly Moderately Quite a bit Very much
4. Anxious, worrying Not at all or very slightly Mildly Moderately Quite a bit Very much
5. Nervous, fidgety Not at all or very slightly Mildly Moderately Quite a bit Very much
6. Inattentive, daydreaming Not at all or very slightly Mildly Moderately Quite a bit Very much
7. Hot- or short-tempered, low boiling point Not at all or very slightly Mildly Moderately Quite a bit Very much
8. Shy, sensitive Not at all or very slightly Mildly Moderately Quite a bit Very much
9. Temper outbursts, tantrums Not at all or very slightly Mildly Moderately Quite a bit Very much
10. Trouble with stick-to-it-tiveness, not following through, failing to finish things started Not at all or very slightly Mildly Moderately Quite a bit Very much
11. Stubborn, strong-willed Not at all or very slightly Mildly Moderately Quite a bit Very much
12. Sad or blue, depressed, unhappy Not at all or very slightly Mildly Moderately Quite a bit Very much
13. Incautious, dare-devilish, involved in pranks Not at all or very slightly Mildly Moderately Quite a bit Very much
14. Not getting a kick out of things, dissatisfied with life Not at all or very slightly Mildly Moderately Quite a bit Very much
15. Disobedient with parents, rebellious, sassy Not at all or very slightly Mildly Moderately Quite a bit Very much
16. Low opinion of myself Not at all or very slightly Mildly Moderately Quite a bit Very much
17. Irritable Not at all or very slightly Mildly Moderately Quite a bit Very much
18. Outgoing, friendly, enioyed company of people Not at all or very slightly Mildly Moderately Quite a bit Very much
19. Sloppy, disorganized Not at all or very slightly Mildly Moderately Quite a bit Very much
20. Moody, ups and downs Not at all or very slightly Mildly Moderately Quite a bit Very much
21. Angry Not at all or very slightly Mildly Moderately Quite a bit Very much
22. Friends, popular Not at all or very slightly Mildly Moderately Quite a bit Very much
23. Well-organized, tidy, neat Not at all or very slightly Mildly Moderately Quite a bit Very much
24. Acting without thinking, impulsive Not at all or very slightly Mildly Moderately Quite a bit Very much
25. Tendency to be immature Not at all or very slightly Mildly Moderately Quite a bit Very much
26. Guilty feelings, regretful Not at all or very slightly Mildly Moderately Quite a bit Very much
27. Losing control of myself Not at all or very slightly Mildly Moderately Quite a bit Very much
28. Tendency to be or act irrational Not at all or very slightly Mildly Moderately Quite a bit Very much
29. Unpopular with other children, did not keep friends for long, did not get along with other children Not at all or very slightly Mildly Moderately Quite a bit Very much
30. Poorly coordinated, did not participate in sports Not at all or very slightly Mildly Moderately Quite a bit Very much
31. Afraid of losing control of self Not at all or very slightly Mildly Moderately Quite a bit Very much
32. Well-coordinated, picked first in games Not at all or very slightly Mildly Moderately Quite a bit Very much
33. Tomboyish (for women only) Not at all or very slightly Mildly Moderately Quite a bit Very much
34. Running away from home Not at all or very slightly Mildly Moderately Quite a bit Very much
35. Getting into fights Not at all or very slightly Mildly Moderately Quite a bit Very much
36. Teasing other children Not at all or very slightly Mildly Moderately Quite a bit Very much
37. Leader bossy Not at all or very slightly Mildly Moderately Quite a bit Very much
38. Difficulty getting awake Not at all or very slightly Mildly Moderately Quite a bit Very much
39. Follower, led around too much Not at all or very slightly Mildly Moderately Quite a bit Very much
40. Trouble seeing things from someone else's point of view Not at all or very slightly Mildly Moderately Quite a bit Very much
41. Trouble with authorities, trouble with school, visits to principal's office Not at all or very slightly Mildly Moderately Quite a bit Very much
42. Trouble with police, booked, convicted Not at all or very slightly Mildly Moderately Quite a bit Very much
Medical problems as a child:
43. Headaches Not at all or very slightly Mildly Moderately Quite a bit Very much
44. Stomachaches Not at all or very slightly Mildly Moderately Quite a bit Very much
45. Constipation Not at all or very slightly Mildly Moderately Quite a bit Very much
46. Diarrhea Not at all or very slightly Mildly Moderately Quite a bit Very much
47. Food allergies Not at all or very slightly Mildly Moderately Quite a bit Very much
48. Other allergies Not at all or very slightly Mildly Moderately Quite a bit Very much
49. Bedwetting Not at all or very slightly Mildly Moderately Quite a bit Very much
As a child in school, I was (or had):
50. Overall a good student, fast Not at all or very slightly Mildly Moderately Quite a bit Very much
51. Overall a poor student, slow learner Not at all or very slightly Mildly Moderately Quite a bit Very much
52. Slow in learning to read Not at all or very slightly Mildly Moderately Quite a bit Very much
53. Slow reader Not at all or very slightly Mildly Moderately Quite a bit Very much
54. Trouble reversing letters Not at all or very slightly Mildly Moderately Quite a bit Very much
55. Problems with spelling Not at all or very slightly Mildly Moderately Quite a bit Very much
56. Trouble with mathematics or numbers Not at all or very slightly Mildly Moderately Quite a bit Very much
57. Bad handwriting Not at all or very slightly Mildly Moderately Quite a bit Very much
58. Able to read pretty well but never really enjoyed reading Not at all or very slightly Mildly Moderately Quite a bit Very much
59. Not achievingup to potential Not at all or very slightly Mildly Moderately Quite a bit Very much
60. Repeating grades Not at all or very slightly Mildly Moderately Quite a bit Very much
61. Suspended or expelled Not at all or very slightly Mildly Moderately Quite a bit Very much
Your Initials:
Who should receive these results? Cancel Maj. Smith, LCSW Dr. Webb