Pediatric Symptom Checklist-17 (PSC-17) – English

INSTRUCTIONS: Emotional and physical health go together in children. Because caregivers are often the first to notice a problem with their child’s behavior, emotions or learning, you may help your child get the best care possible by answering these questions. Please select the responses that best fit your child.

This code will be provided by your UF Care Coordinator. Please DO NOT use Patient's Name or Date of Birth, DO NOT use Patient's Medical Record Number, DO NOT use Patient's SS#.

Internalizing - positive if 5 or greater

I1. Does your child feel sad?(Required)
I2. Does your child feel hopeless?(Required)
I3. Does your child feel down on him/herself?(Required)
I4. Does your child worry a lot?(Required)
I5. Does your child seem to be having less fun?(Required)

Attention - positive if 7 or greater

A6. Does your child fidget, or is unable to sit still?(Required)
A7. Does your child daydream too much?(Required)
A8. Does your child distract easily?(Required)
A9. Does your child have trouble concentrating?(Required)
A10. Does your child act as if driven by a motor?(Required)

Externalizing - positive if 7 or greater

E11. Does your child fight with other children?(Required)
E12. Does your child not listen to rules?(Required)
E13. Does your child not understand other people’s feelings?(Required)
E14. Does your child tease others?(Required)
E15. Does your child blame others for his/her troubles?(Required)
E16. Does your child refuse to share?(Required)
E17. Does your child take things that do not belong to him her?(Required)