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Strengths and Difficulties Questionnaire (Parent 4-10)

For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of your child's behavior over the last six months.

Your child's name Male Female

Date of Birth

	Not True	Somewhat True	Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children, for example toys, treats, pencils
Often loses temper
Rather solitary, prefers to play alone
Generally well behaved, usually does what adults request
Many worries or often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, depressed or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies or cheats
Picked on or bullied by other children
Often offers to help others (parents, teachers, other children)
Thinks things out before acting
Steals from home, school or elsewhere
Gets along better with adults than with other children
Many fears, easily scared
Good attention span, sees chores or homework through to the end

Do you have any other comments or concerns?

Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behavior or being able to get on with other people?

No Yes - minor difficulties Yes - definite difficulties Yes - severe difficulties

If you have answered "Yes", please answer the following questions about these difficulties:

How long have these difficulties been present?

Less than a month 1-5 months 6-12 months Over a year

Do the difficulties upset or distress your child?

Not at all Only a little A medium amount A great deal

Do the difficulties interfere with your child's everyday life in the following areas?

	Not at all	Only a little	A medium amount	A great deal
HOME LIFE
FRIENDSHIPS
CLASSROOM LEARNING
LEISURE ACTIVITIES

Do the difficulties put a burden on you or the family as a whole?

Not at all Only a little A medium amount A great deal

Signature: Date:

Mother/Father/Other (please specify:)

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October 9, 2021 10:54 am CDT

Strengths and Difficulties Questionnaire (Parent 4-10) Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12