One Page Checklist
One Page Checklist:
Name:____________________________________________Age:______DOB:_______Date:____________
Read each item carefully, then 1. CHECK IF the Number APPLIES, THEN 2. CIRCLE the Specific Item to Clarify
1. [ ] Hyperactive, overly active, on the go, can’t sit still, and/or an inner sense of restlessness
2. [ ] Distractible, Sometimes? Mostly? Can’t concentrate, pay attention on boring stuff, for 15 minutes
3. [ ] Impulsive, doesn’t stop and think of consequences before talking or doing, or further thinking
4. [ ] Delay or improper use of language, play-pretend get stuck on one idea over, especially sexual, violent
5. [ ] Poor eye contact, doesn’t seem to get social things like greetings, jokes, sorrows, need to love, to grieve
6. [ ] Gets angry/fearful to change in routines ,sensitivities to, sound, touch, light, taste, smells, foods
7. [ ] Colicky as infant, presently unpleasant, irritable, nasty, mean, severe tantrums, bossy, the bully
8. [ ] Severe separation anxiety, frequent school absences, migraines, headaches, frequently ill, always sick
9. [ ] Short fuse, easily made angry, can’t calm self down within 20 min, severe temper, rage attacks
10. [ ] Mood swings, unpredictable, ups and downs of feelings, driven by moods, Dr Jekle & Mr.Hyde,
11. [ ] Can’t control anger, breaking things, self mutilating, dangerous to others, talks about killing others
12. [ ] Unaware of time, place, who you are, dazed, lost in time, confused, sleep like, or trance like states
13. [ ] Hurting self, cuts self, punches things, talk of suicide, being better off dead, dangerous to self
14. [ ] Sleep difficulties, sleeps too much/ too little, wakes up, dreams seem real, nightmares, wets bed,
15. [ ] Talks too much, too fast, not logical, difficult to follow, talks in circles, doesn’t always makes sense
16. [ ] Feeling sad, crying, saying negative things, not normal self, easily bored, things are less fun, isolates self
17. [ ] Excessive eating, especially in evening, waking up after asleep and eating, eats to calm down
18. [ ] Overly suspicious, holds grudges paranoid, thoughts seem like voices, odd, bizarre, strange, weird
19. [ ] Too worried, afraid to do things, go places, shy, stage fright, panic attacks, heart beats fast, sweats easily
20. [ ] Excessive eye blinking, facial movements, throat clearing, sniffing, snorting, coughing,
21. [ ] Does things over and over, rituals, touching, counting, hand washing, ordering, putting things in sequence
22. [ ] Over use or can’t stop TV, video games, computer time, food, exercise, using drugs, alcohol, tobacco
23. [ ] Trouble in reading, spelling, math, other learning problems, speech, stuttering, co ordination difficulties
24. [ ] Witnessed domestic violence, victim of neglect, physical and/or sexual abuse, natural catastrophe
25. [ ] Cruel to animals, cruel to people, nasty, mean, seems to lack conscience, no or little remorse, guilt, shame