CHILD BEHAVIOR CHECKLIST
Child’s Name: _________________________ Birth date: ______________________
Child’s Name: _________________________ Birth date: ______________________
Teacher / Observer: _______________________ Date tested: 1. _______ 2. ________
Please answer all items as well as you can, even if some do not seem to apply to the child.
0 = Not True (as far as you know) 1 = somewhat or Sometimes True 2 = Very True or Often True
0 1 2 1. Aches or pains (without medical cause; do
not include stomach or headaches)
0 1 2 2. Acts too young for age
0 1 2 3. Afraid to try new things
0 1 2 4. Avoids looking others in the eye
0 1 2 5. Can’t concentrate, can’t pay attention for long
0 1 2 6. Can’t sit still, restless, or hyperactive
0 1 2 7. Can’t stand having things out of place
0 1 2 8. Can’t stand waiting; wants everything now
0 1 2 9. Chews on things that aren’t edible
0 1 2 10. Clings to adults or too dependent
0 1 2 11. Constantly seeks help
0 1 2 12. Constipated, doesn’t move bowels (when not
sick)
0 1 2 13. Cries a lot
0 1 2 14. Cruel to animals
0 1 2 15. Defiant
0 1 2 16. Demands must be met immediately
0 1 2 17. Destroys his/her own things
0 1 2 18. Destroys things belonging to his/her family
or other children
0 1 2 19. Diarrhea or loose bowels (when not sick)
0 1 2 20. Disobedient
0 1 2 21. Disturbed by any change in routine
0 1 2 22. Doesn’t want to sleep alone
0 1 2 23. Doesn’t answer when people talk to him/her
0 1 2 24. Doesn’t eat well (describe): ________________
______________________________________
0 1 2 25. Doesn’t get along with other children
0 1 2 26. Doesn’t know how to have fun; acts like a
little adult
0 1 2 27. Doesn’t seem to feel guilty after misbehaving
0 1 2 28. Doesn’t want to go out of home
0 1 2 29. Easily frustrated
0 1 2 30. Easily jealous
0 1 2 31. Eats or drinks things that are not food—don’t
include sweets (describe): _________________
______________________________________
0 1 2 32. Fears certain animals, situations, or places
(describe): _____________________________
______________________________________
0 1 2 33. Feelings are easily hurt
0 1 2 34. Gets hurt a lot, accident-prone
0 1 2 35. Gets in many fights
0 1 2 36. Gets into everything
0 1 2 37. Gets too upset when separated from parents
0 1 2 38. Has trouble getting to sleep
0 1 2 39. Headaches (without medical cause)
0 1 2 40. Hits others
0 1 2 41. Holds his/her breath
0 1 2 42. Hurts animals or people without meaning to
0 1 2 43. Looks unhappy without good reason
0 1 2 44. Angry moods
0 1 2 45. Nausea, feels sick (without medical cause)
0 1 2 46. Nervous movements or twitching
(describe): _____________________________
______________________________________
0 1 2 47. Nervous, highstrung, or tense
0 1 2 48. Nightmares
0 1 2 49. Overeating
0 1 2 50. Overtired
0 1 2 51. Shows panic for no good reason
0 1 2 52. Painful bowel movements (without medical
cause)
0 1 2 53. Physically attacks people
0 1 2 54. Picks nose, skin, or other parts of body
(describe): _____________________________
0 1 2 55. Shows little affection toward people
0 1 2 56. Shows little interest in things around him/her
0 1 2 57. Shows too little fear of getting hurt
0 1 2 58. Too shy or timid
0 1 2 59. Sleeps less than most kids during day
and/or night (describe): _________________
___________________________________
0 1 2 60. Smears or plays with bowel movements
0 1 2 61. Speech problem (describe): _____________
___________________________________
0 1 2 62. Stares into space or seems preoccupied
0 1 2 63. Stomachaches or cramps (without medical
cause)
0 1 2 64. Rapid shifts between sadness and
excitement
0 1 2 65. Strange behavior (describe): ____________
___________________________________
0 1 2 66. Stubborn, sullen, or irritable
0 1 2 67. Sudden changes in mood or feelings
0 1 2 68. Sulks a lot
0 1 2 69. Talks or cries out in sleep
0 1 2 70. Temper tantrums or hot temper
0 1 2 71. Too concerned with neatness or cleanliness
0 1 2 72. Too fearful or anxious
0 1 2 73. Uncooperative
0 1 2 74. Underactive, slow moving, or lacks energy
0 1 2 75. Unhappy, sad, or depressed
0 1 2 76. Unusually loud
0 1 2 77. Upset by new people or situations
(describe): __________________________
___________________________________
0 1 2 78. Vomiting, throwing up (without medical cause)
0 1 2 79. Wakes up often at night
0 1 2 80. Wanders away
0 1 2 81. Wants a lot of attention
0 1 2 82. Whining
0 1 2 83. Withdrawn, doesn’t get involved with others
0 1 2 84. Worries
0 1 2 85. Please write in any problems the child has
that were not listed above.
0 1 2 _____________________________________
For parents
I. Was your child born earlier than the usual 9 months after conception?
G No G YesChow many weeks early? ________weeks early.
II. How much did your child weigh at birth? ________ pounds ________ounces; or ________ grams.
III. How many ear infections did your child have before age 24 months?
G 0-2 G 3-5 G 6-8 G 9 or more
IV. Is any language beside English spoken in your home?
G No G Yes—please list the languages: ___________________ ___________________
___________________ ___________________
V. Has anyone in your family been slow in learning to talk?
G No G Yes—please list their relationships to your child; for example, brother, father:
________________________________________________________________________
VI. Are you worried about your child’s language development?
G No G Yes—why? ________________________________________________________
_____________________________________________________________
VII. Does your child spontaneously say words in any language? (not just imitates or understands words)?
G No G Yes—if yes, please complete item VIII and page 4.
VIII. Does your child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”
G No G Yes—please print 5 of your child=s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. ___________________________________________________________
Problem Checklist
Put Check if the situation is occurred.
VICTIM
He/ She was crying
He/ She injured from his/her classmates
He/ She have damage on his/her head, arms, thigh, etc.
He/ She has bite marks and wounds
He/ She is often easily disturbed y extraneous stimuli
He/ She is often loses things necessary for tasks or activities such as toys, school assignment etc.
He/ She I can’t talk or speak well because he/she feels shame and afraid
He/ She is often spiteful by his/her classmates
He/ She is often loses one’s temper
SUSPECT
He/ She was hitting, kicking, or threatening to his/her classmates
He/ She pushed his/her classmates.
He/ She don’t get his/her personal things, and then he/she spanked his/her
Classmate.
He/ She has bullying his/ her classmates
He/ She was biting his/her classmates
He/ she always aggressive
He/ She is always say bad words to his/ her Classmates
He/ She are often angry and resentful to his/her classmates.
He/ She blame other classmates for one’s mistakes or misbehavior.
TEACHERS
He/ She asked each of the children regarding the problem
He/ She were shouting to his/her children.
He/ She ignored the problem situation
He/ She shocked in the situation
He/ She is angry and take the children outside the room
He/ She used force to stop the quarreling or fighting between two children
He/ She used activities to catch up their attention
He/ She hurt his/her children.
He/ She talked to the children about the situation
He/ she didn’t know what happened and what he/she can do
He/ She were crying.
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