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Child Health Questionnaire Checklist

Child Health Questionnaire Checklist

Laura Cooper Peterson

Laura Cooper Peterson

created on Dec 25, 2011

UselessPoorOkGoodExcellent

Excellent

4.77 with 90 votes

Behavior and temperament

Prefers to play alone

Better with one on one interaction

Does not smile as often

Seems depressed

Is anxious

Hyperactive or restless

Unable to disregard unimportant stimuli

Impulsive

Disruptive

Easily distracted

Forgetful

Physically abusive

Verbally abusive

Frequent tantrums

Mood swings for no reason

Short attention span

Uncomfortable in crowds

Becomes easily annoyed

Bothered by loud noises

Bothered by bright lights

Shows little remorse

Emotionally unstable

Little interest or pleasure in doing things

Jekyll-and-Hyde type of personality

Autistic tendencies (if applicable)

Shows little to no eye contact

Speech is literal

Content and happier to be alone

Seems to be in “own world”

Lacks displays of affection

Lacks response from others

Does not point out objects of interest to others

Indifferent to surroundings

Lacks interest in toys

Marked reduction in activity level

Increase in activity level

Over-sensitive to pain

Under-sensitive to pain

Undeveloped motor skills

Does not understand consequences

Lines things up

Loves patterns

Color coordinated objects

Inappropriate attachment to objects

Displays daily obsessive routines

Medication side effects

Behavior changes

Stomach upset/aches

Mouth burns

Leg / calf cramps

Drowsiness

Confusion

Clumsiness

Nausea

Unresponsive at times

Mental confusion

Lethargic

Tired or tense a lot

Learning and cognition

IQ lower than average

Unable to process new information

Unable to retain new information

Has trouble performing daily tasks

Needs constant reminders

Does not carry on full conversation

Repeats sentences

Talks to himself

Delay in academic achievement

Lacks common sense

Is a slow starter

Moves slowly

Speaks slowly

Other questions of interest

Eyes are “glazed over”

Breaks out in rashes/hives

Has eczema

Fidgety or restless

Is vomiting a problem

Has recurrent colds

Eating or not eating affects behavior

Facial color is pale

Dark circles under eyes

Headaches

Stomach viruses often

Wets the bed or self

Constipated often

Diarrhea often

Craves certain foods

Has ear infections

Poor appetite

Gets car sick

Odor or fumes make them sick

Loves the smell of gas or paint

Trouble going to sleep

Would steal chocolate

Has food cravings like milk, peanut butter, eggs

Asthma

Tonsillitis, strep throat

Very ticklish

Clears throat a lot

Walks on tip toes

Has dry skin

UselessPoorOkGoodExcellent

Excellent

4.77 with 90 votes

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