PROBLEM CHECKLIST
Name: _____________________________________ Date:_________________
Individual Problem Checklist
Directions:
Put a number next to any item which you experience. 1=mildly, 2=moderately, 3=severely
Emotional Concerns
____feeling anxious or uptight
____excessive worrying
____not being able to relax
____feeling panicky
____unable to calm yourself down
____dwelling on certain thoughts or images
____fearing something terrible about to happen
____avoiding certain thoughts or feelings
____having strong fears
____worrying about a nervous breakdown
____feeling out of control
____avoiding being with people
____fears of being alone or abandoned
____feeling guilty
____having nightmares
____flashbacks
____troubling or painful memories
____missing periods of time - can't remember
____trouble remembering things
____feeling numb instead of upset
____feeling detached from all or part of body
____feeling unreal, strange or foggy
____feeling depressed or sad
____being tired or lacking energy
____feeling unmotivated
____loss of interest in many things
____having trouble concentrating
____having trouble making decisions
____feeling the future looks hopeless
____feeling worthless or a failure
____being unhappy all the time
____dissatisfied with physical appearance
____feeling self critical or blaming yourself
____having negative thoughts
____crying often
____feeling empty
____withdrawing inside yourself
____thinking too much about death
____thoughts of hurting yourself
____thoughts of killing yourself
____frequent mood swings
____feeling resentful or angry
____feeling irritable or frustrated
____feeling rage
____feeling like hurting someone
__________________________________________________
Behavioral and Physical Concerns
____not having an appetite
____eating in binges
____self induced vomiting for weight control
____using laxatives for weight control
____eating too much
____eating too little
____losing weight - how much?_____
____gaining weight - how much?____
____trouble sleeping
____trouble falling asleep
____early morning awakening
____sleeping too much
____sleeping too little
____# of hours I usually sleep: _____
____lack of exercise
____not having leisure activities
____smoking cigarettes
____often spending in binges
____temper outbursts
____aggressive toward others
____impulsive reactions
____trouble finishing things
____working too hard
____using alcohol too much
____being alcoholic
____using drugs
____driving under the influence
____blackouts - after drinking
___Yes ___No Have you ever felt you ought to cut
down on your drinking or drug use?
___Yes ___No Have people annoyed you by
criticizing your drinking or drug use?
___Yes ___No Have you ever felt bad or guilty
about your drinking or drug use?
___Yes ___No Have you ever had a drink or used
drugs first thing in the morning to
steady your nerves or to get rid of a hangover?
_______________________________________________
Intimate Relationship Concerns
____feeling misunderstood in relationship
____not feeling close to partner
____trouble communicating with partner
____not trusting partner
____lack of respect by partner
____partner being secretive
____lack of fairness in relationship
____problems with dividing household tasks
____disagreeing about children
____lack of affection
____unsatisfactory sexual relationship
____lack of time together
____lack of shared interests
____lack of positive interaction ____lack of time with other couples
____jealousy in relationship
____frequent arguments
____trouble resolving conflict
____partner being demanding and controlling
____partner putting you down
____violent arguments
____emotional abuse in relationship
____physical abuse in relationship
____sexual abuse in relationship
____partner having alcohol or drug problem
____self or partner having an affair
____feeling uncommitted to relationship
____wanting to separate
____discussing separating or divorce
____problems with in-laws
____problems with ex-partner
____problems with step parents
____children having special problems
_________________________________________________
Sexual Concerns
____worrying about getting pregnant
____having miscarriage(s)
____choice of birth control
____having an abortion
____not able to become pregnant
____not enjoying sexual affection
____too tired to have sex
____too anxious to have sex
____feeling a lack of sexual desire
____wanting to have sex more often
____feeling neglected sexually
____feeling used sexually
____feeling unable to have orgasm
____being unable to sustain an erection
____feeling negatively about sex
_________________________________________________
When Growing Up to Present Time:
____being physically abused - by whom?
____being emotionally abused - by whom?
____being sexually abused - by whom?
____having an alcoholic parent - which?
____having a drug abusing parent - which?
____having a depressed parent - which?
____having a parent with emotional problems
____having parents separate or divorce
____close family member dying - who?
____felt neglected or unloved - by whom
____having an unhappy childhood
____having serious medical problems - what?
____having drug or alcohol problem
____frequent moves
____having learning problems - what?
____having emotional problems
____having attempted suicide - when?
___________________________________________________
Stresses During the Past Several Years:
____death of family member or friend - who?
____birth or adoption of child
____self or family member hospitalized - who?
____moved
____being harassed or assaulted
____frequent family or couple arguments
____separation/divorce
____an important relationship ending - who?
____losing or changing job
____financial trouble
____legal problems
____natural disaster
____serious or chronic illness
Problem Checklist
Put Check if the situation is occurred.
He/ She was crying
He/ She injured from his/her classmates
He/ She have damage on his/her head, arms, thigh, etc.
He/ She has bite marks and wounds
He/ She is often easily disturbed y extraneous stimuli
He/ She is often loses things necessary for tasks or activities such as toys, school assignment etc.
He/ She I can’t talk or speak well because he/she feels shame and afraid
He/ She is often spiteful by his/her classmates
He/ She is often loses one’s temper
He/ She was hitting, kicking, or threatening to his/her classmates
He/ She pushed his/her classmates.
He/ She don’t get his/her personal things, and then he/she spanked his/her
He/ She has bullying his/ her classmates
He/ She was biting his/her classmates
He/ she always aggressive
He/ She is always say bad words to his/ her Classmates
He/ She are often angry and resentful to his/her classmates.
He/ She blame other classmates for one’s mistakes or misbehavior.
FOR TEACHERS
He/ She asked each of the children regarding the problem
He/ She were shouting to his/her children.
He/ She ignored the problem situation
He/ She shocked in the situation
He/ She is angry and take the children outside the room
He/ She used force to stop the quarreling or fighting between two children
He/ She used activities to catch up their attention
He/ She hurt his/her children.
He/ She talked to the children about the situation
He/ she didn’t know what happened and what he/she can do
He/ She were crying.
Please answer all items as well as you can, even if some do not seem to apply to the child.
A = Not True (as far as you know) B = somewhat or Sometimes True
C = Very True or Often True
A B C 1. Cries a lot
A B C 2. Cruel to animals
A B C 3. Defiant
A B C 4.. Demands must be met immediately
A B C 5. Destroys his/her own things
A B C 6. Destroys things belonging to his/her family
or other children
A B C 7. Diarrhea or loose bowels (when not sick)
A B C 8. Disobedient
A B C 9. Disturbed by any change in routine
A B C 10. Doesn’t want to sleep alone
A B C 20. Doesn’t answer when people talk to him/her
A B C 21. Doesn’t eat well (describe): ________________
______________________________________
A B C 22. Doesn’t get along with other children
A B C 23. Doesn’t know how to have fun; acts like a
little adult
A B C 24. Doesn’t seem to feel guilty after misbehaving
A B C 25. Doesn’t want to go out of home
A B C 26. Easily frustrated
A B C 27. Easily jealous
A B C 28. Eats or drinks things that are not food—don’t
include sweets (describe): _________________
______________________________________
A B C 29.Fears certain animals, situations, or places
(describe): _____________________________
______________________________________
A B C 30. Feelings are easily hurt
A B C 31 Gets hurt a lot, accident-prone
A B C 32. Gets in many fights
A B C 33. Gets into everything
LANGUAGE DEVELOPMENT
Be sure to answer all items.
I. Was your child born earlier than the usual 9 months after conception?
G No G Yes how many weeks early? ________weeks early.
II. How much did your child weigh at birth? ________ pounds ________ounces; or ________ grams.
III. How many ear infections did your child have before age 24 months?
G 0-2 G 3-5 G 6-8 G 9 or more
IV. Is any language beside English spoken in your home?
G No G Yes—please list the languages: ___________________ ___________________
___________________ ___________________
V. Has anyone in your family been slow in learning to talk?
G No G Yes—please list their relationships to your child; for example, brother, father:
________________________________________________________________________
VI. Are you worried about your child’s language development?
G No G Yes—why? ________________________________________________________
_____________________________________________________________
VII. Does your child spontaneously say words in any language? (not just imitates or understands words)?
G No G Yes—if yes, please complete item VIII and page 4.
VIII. Does your child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”
G No G Yes—please print 5 of your child=s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.
1. _______________________________________________________________
2. _______________________________________________________________
3. _______________________________________________________________
4. _______________________________________________________________
5. _______________________________________________________________
Please circle each word that your child says SPONTANEOUSLY (not just imitates or understands).
FOODS
1. apple
2. banana
3. bread
4. butter
5. cake
6. candy
7. cereal
8. Cheese
9. coffee
10. cookie
TOYS
11. ball
12. balloon
13. blocks
14. book
15. crayons
16. doll
17. picture
18. present
19. slide
20. swing
BODY PARTS
21. arm
22. belly button
23. bottom
24. chin
25. ear
26. elbow
27. eye
28. face
29. finger
30. foot
Other words your child says,
including non-English words:
______________________________
______________________________
______________________________
______________________________
If Problems Arise
Sometimes child care programs
that are wonderful take a sudden
turn for the worse. That’s why it
is important to keep a watchful
eye and to continually monitor
your child care situation. If you
believe that your child care
arrangement is not safe, take
immediate action. If the situation
is serious, do not hesitate to find
alternative care right away. After
all, you alone are most
responsible for your child’s
health and safety.
Remember also that you have a
responsibility to other children to
see that they are well cared for.
Express your concerns to the
caregiver, and report concerns to
the Department of Human
Services or your local licensing
agency. It may feel uncomfortable
at first, but it is the right
thing to do. Our children deserve
the very best care that we can give
