| Criteria- Within the past six months |
Not at all or very slightly |
Mildly |
Moderately |
Quite a bit |
Very much |
As a Child in school I was or had:
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| 1. Active, restless, always on the go |
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| 2. Afraid of things |
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| 3. Concentration problems, easily distracted |
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| 4. Anxious, worrying |
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| 5. Nervous, fidgety |
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| 6. Inattentive, daydreaming |
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| 7. Hot or short tempered; low boiling point |
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| 8. Shy, sensitive |
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| 9. Temper outbursts, tantrums |
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| 10. Trouble with stick-to-it-ness, not following through; failing to finish things started |
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| 11. Stubborn; strong willed |
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| 12. Sad or blue; depressed; unhappy |
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| 13. Incautious. Dare devilish. Involved in pranks |
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| 14. Not getting a kick out of things; Dissatisfied with life |
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| 15. Disobedient with parents. Rebellious. Sassy |
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| 16. Low opinion of oneself |
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| 17. Irritable |
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| 18. Outgoing, friendly, enjoyed thecompany of people |
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| 19. Sloppy & disorganised |
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| 20. Moody with ups and downs |
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| 21. Angry |
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| 22. Alot of friends. Popular |
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| 23. Well organised, tidy, neat |
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| 24. Impulsive. Act without thinking |
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| 25. Tendency to be immature |
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| 26. Guilty feeling. Regretful |
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| 27. Lose control of myself |
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| 28. Tendency to be or act irrational |
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| 29. Unpopular with other children. Didn't keep friends for long. Didn't get along with other children |
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| 30. Poorly coordinated. Didn't participate in sports |
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| 31. Afraid of losing self control |
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| 32. Well coordinated. Picked first in games |
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| 33. Tomboyish (for women only) |
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| 34. Runs away from home |
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| 35. Gets into fights |
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| 36. Teases other children |
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| 37. Leader. Bossy |
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| 38. Difficulty waking up |
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| 39. A follower. Led around too much |
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| 40. Trouble seeing things from other people's point of view |
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| 41. Trouble with authorities, school, or frequent visits to the principal's office |
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| 42. Trouble with police. Charged. Convicted |
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| 43. Headaches |
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| 44. Stomachaches |
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| 45. Constipation |
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| 46. Diarrhea |
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| 47. Food alleries |
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| 48. Other allergies |
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| 49. Bed wetting (urinesis) |
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| 50. Overall a good student. Fast |
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| 51. Overall a poor student. A slow learner |
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| 52. Slow in learning to read |
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| 53. Slow reader |
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| 54. Trouble with letter reversal |
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| 55. Problems with spelling |
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| 56. Trouble with mathematics or numbers |
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| 57. Poor handwriting |
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| 58. Able to read pretty well but never enjoyed reading |
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| 59. Not achieving up to potential |
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| 60. Repeating grades |
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| 61.Suspended or expelled |
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