Bellevue Pediatrics

Bellevue Pediatrics

Today's Date * Patient's Name * Patient's DOB *

Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions or learning, you may help your child get the best care possible by answering these questions. Please mark the one that best fits your child.

1. Complains of aches/pains 2. Spends more time alone 3. Tires easily, has little energy 4. Fidgety, unable to sit still 5. Has trouble with a teacher 6. Less interested in school 7. Acts as if driven by a motor 8. Daydreams too much 9. Distracted easily 10. Is afraid of new situations 11. Fells sad, unhappy 12. Is irritable, angry 13. Feels hopeless 14. Has trouble concentrating 15. Less interest in friends 16. Fights with others 17. Absent form school 18. School grades dropping 19. Is down on him or herself 20. Visits doctor with doctor finding nothing wrong 21. Has trouble sleeping 22. Worries a lot 23. Wants to be with you more than before 24. Fells he or she is bad 25. Takes unnecessary risks 26. Gets hurt frequently 27. Seems to be having less fun 28. Acts younger than children his or her age 29. Does not listen to rules 30. Does not show feelings 31. Does not understand other people's feelings 32. Teases others 33. Blames others for his or her troubles 34. Takes things that do not belong to him or her 35. Refuses to share Does your child have any emotional or behavioral problems for which she/he needs help? Are there an services that you would like your child to receive for these problems? If yes, what services?