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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

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Child Health Questionnaire Checklist

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