Republic of the Philippines

Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

THE ANXIETY DISORDER CHECKLIST

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

DISTURBED SLEEP 0 1 2 3
Has difficulties getting to sleep, scared of the dark, heard noises, etc.
Is afraid of being alone at night.
Has nightmares or night terrors.

AFRAID OF NEW EXPERIENCES 0 1 2 3

Wants to do something new but panics at the last minute and will not go.
Worries excessively before a new experience.
Refuses t try new things because of anxiety.
Panics when a new experience is forced on him/her.
Gets extremely anxious before the start of a new school week, term or year.
Needs a lot of preparation before being able to cope with new experience.
Hides or lock self away to avoid anxiety- provoking situations.

HAS PHYSICAL SIGNS OF ANXIETY 0 1 2 3

Has nervous blink, twitch, or other mannerism.
Feels numb or complains of tingling sensations.
Gets sweaty palm when anxious.
Goes pale under pressure.
Vomits (or feels nauseous) in stressful situations.
Has breathing difficulties or choking sensation when anxious
Has panic attacks and becomes visibly overwhelmed by anxiety.
Complains of increased or irregular heart rate.
Has a tantrum or clings when frightened or anxious.
Freezes and will not move or speak when anxious.
Is afraid of dying, going crazy, or losing control.
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

THE ANXIETY DISORDER CHECKLIST (Cont.)

ANXIOUS ABOUT BEING SEPARATED FROM PARENTS 0 1 2 3

Resists being separated from parent (e.g., at start of school day).
Worries about parents well – being when separated from them.
Is reluctant to sleep without parent being near.
Is reluctant to stay away from home overnight.
Worries about how long it will be before parents return to pick him or her up.
Panics if parents are not there at the appointed time.

SPECIFIC PHOBIAS 0 1 2 3
Has extreme fear of animals (a particular animal or insect, or animals in general)
Is frightened by clowns or other entertaining characters.
Cannot watch cartoons suitable for age group without being frightened.
Is over anxious about medical or dental procedures, refuses treatments, panics.
Is very fearful of going into some places.
Is excessively anxious about everyday risks (e.g., storms, thunder, water).
Is very uncomfortable in enclosed or crowded spaces.
Has excessive anxiety about germs, accidents, death and illness.

OBSESSIONS OR COMPULSIONS 0 1 2 3
Attempts to prevent a dreaded event by obsessional behavior.
Is distressed by thoughts, images or impulses that will not go away.

UNUSUALLY UPSET BY TRAGIC EVENTS 0 1 2 3

Is made extremely anxious by news items about disasters, terrorism attacks, etc.
Plans elaborate escape or protection strategies to avoid possible traumas.
Talks excessively about catastrophes that have occurred or might occur.
Continually asks for reassurance about possible catastrophes.
Has a prolonged and severe reaction he or she has experienced.

SOCIAL ANXIETY 0 1 2 3
Is excessively shy with unfamiliar person.
Is unusually reluctant to participate in group activities appropriate to age.
Is very sensitive and self-conscious, very easily humiliated or embarrassed.
Dislikes being watched, even in everyday activities such as eating or playing.
Is very shy and reluctant to perform even in a group.
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

THE ANXIETY DISORDER CHECKLIST (Cont.)

FAMILY HISTORY YES NO DON’T KNOW

Other family members have (or have had) an anxiety disorder

Additional comments and observations

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

THE SELECTIVE MUTISM CHECKLIST

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

UNWILLINGNESS TO SPEAK 0 1 2 3
Is reluctant to speak to anyone outside of family home.
Is reluctant to speak to visitors to the family home.
Is willing to speak to some family members but not others.
May speak to children bu not adults outside of the home.
Is unwilling to speak to familiar people when observed by a stranger.
Shows unwillingness to speak in first language (if multilingual)

ADEQUATE LANGUAGE DEVELOPMENT 0 1 2 3

Does communicate adequately with familiar people.

SUBTLE LANGUAGE DIFFICULTIES 0 1 2 3

Was later than average in learning to talk.
Has subtle language difficulties that are not easily recognized.

USE OF NONVERBAL COMMUNICATION 0 1 2 3

Use gesture to communicate.
Nods or shakes head appropriately when spoken to.
Uses physical communication (e.g., leads adult by the hand to indicate needs).
Uses short, monotone grunts in pace of words.
Joins in group singing but may stop if watched.
May stare blandly when spoken to.
May avoid eye contact.

PROBLEM LASTS FOR MORE THAN A MONTH 0 1 2 3

Has been unwilling to speak to some people for at least a month.
Has been unwilling to speak in some settings for at least a month.
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

THE SELECTIVE MUTISM CHECKLIST (Cont.)

PROBLEM DOES NOT RESOND TO PRESSURE 0 1 2 3

Cannot be bribed into speaking.
Does not respond to threats or punishments.

THERE ARE NO OTHER REASONS FOR YES NO DON’T KNOW

UNWILLINGNESS TO SPEAK
Is emotionally disturbed.
Has been traumatized.
Is autistic.
Has Cognitive Disability or Mental Retardation.
Has a receptive or expressive language disorder.
Is seriously ill.

HAS HAD APPROPRIATE OPPORTUNITY TO SPEAK YES NO DON’T KNOW

Speaks the same language as others.
Can hear adequately
Has had normal socialization.

CAUTIOUS PERSONALITY 0 1 2 3
Is chronically shy
Does not like to take risks of any kind.
Is low to gain confidence in new situations.

INFLEXIBILITY 0 1 2 3
Is often stubborn over small matters.
Was slow or resistant to toilet training.
Is very picky to foods, clothes, etc.
Often has tantrums if unable to get his or her own way.
Can be rigid about routines.
Does not like change.
Can sometimes be obsessional, excessively neat, or fussy.
Does not like unusual textures, tastes or physical sensations.

FAMILY HISTORY YES NO DON’T KNOW

Other family members may have been similar in childhood.
Family history of language disorder.
At least one parent is quiet and reclusive.

THE SELECTIVE MUTISM CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

Additional comments and observations

THE CHILD AND ADOLESCENT DEPRESSION CHECKLIST

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

NEGATIVE MOOD 0 1 2 3
Is negative about most things.
Complains of being “fed-up”.
Complains of being bored.
Often seems sad.
Often seems flat and emotionless.
Often seems angry and bad tempered.
Cries easily.
Irritable and touchy.

LOSS OF INTEREST AND ENJOYMENT 0 1 2 3

Has lost interest in things that used to be enjoyed.
Not interested if suitable activities are suggested.
Has lost sense of humor.
Seems lazy and disinterested in most things.
Does not seem to care about success in school work, sports, etc.
Is hard to please.
Says there is no point to things.
Complains a lot.

SOCIAL ISOLATION 0 1 2 3
Is bad tempered and uncommunicative (especially with adults).
Will not willingly join in family or peer group activities
Stays alone in his or her room for long periods of time.
Is excessively absorbed by music, computer games, cartoons, comics, etc.
Does not contact friends out of school.
Thinks people are deliberately trying to upset or annoy him or her.
Reluctant to attend school.
Says nothing is wrong when asked.

THE CHILD AND ADOLESCENT DEPRESSION CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

PEER GROUP DEPENDENCE 0 1 2 3

Engages in risky exploits with peers.
Seems to enjoy being with peers, but is bad tempered and uncommunicative with
adults.
Disobeys adult limits on behavior.
Has excessive needs to be with friends.
Is attention seeking and disruptive at school.

CHANGES IN ENERGY LEVELS 0 1 2 3

Seems to be tired most of the times.
Is often sleepy, and slow to respond.
Is often troubled or nervous and restless.

DISTURBED EATING OR SLEEPING PATTERNS 0 1 2 3

Has difficulty in getting to sleep or staying asleep.
Sleeps an excessive amount or at unusual times.
Eats much less than usual, not interested in food.
Eats an excessive amount but may not be selective.
Use alcohol or drugs to excess.

POOR CONCENTRATION 0 1 2 3
Often seems to be indecisive.
Often seems forgetful.
Is often poorly organized.
Often seems vague and unattentive.

LOW SELF- ESTEEM 0 1 2 3

Does not seem to expect success.
Says he or she is stupid, dumb, etc.
Finds it hard to accept criticism.
Finds it hard to accept praise or affection.
Says he or she would be better off dead.
Says parents prefer or favor other children in family.
Says teachers prefer or favor other student in class.
Is inappropriately apologetic or excessively guilty about minor issues.

THE CHILD AND ADOLESCENT DEPRESSION CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

PRE OCCUPATION WITH NEGATIVE, VIOLENT, OR MORBID IDEAS 0 1 2 3

Draws and writes on negative, violent or morbid topics.
Talks about suicide (in general or in relation to himself or herself).
Seems overly interested in songs, news items or films about violence and death.
Has taken risks that could be suicidal.

FAMILY HISTORY YES NO DON’T KNOW

Family history of depression or other mental illness.

Additional comments and observations

THE CONDUCT DISORDER CHECKLIST

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

SOCIALLY INAPPROPRIATE BEHAVIOR 0 1 2 3

Has little empathy or concern for other people.
Bullies or intimidate others.
Associates with other anti-social youngsters.
Is intolerant of minority group.
Is outspoken and rude.
Does not respect other’s rights (e.g., to learn, to enjoy peace and quiet).
Is a poor judge of other people, mistakenly thinks they are hostile or threatening.
Engages in sexually promiscuous behavior (unselective of sexual relationships).
Shows little guilt or remorse for wrongdoing.

DESTRUCTIVE 0 1 2 3
Deliberately spoils or destroys other people’s possessions.
Sets fires, deliberately knowing that this will cause serious damage.
Vandalizes public property (graffiti or writings on walls, smashing glass).

DISRESPECTFUL OF ADULT AUTHORITY 0 1 2 3

Ignores parental rules or requests.
Ignores school rules.
Breaks the law.
Runs away from home.
Is truant (stays away without leave or explanation) from school.
Does not comply with punishments.
Is frequently suspended or expelled from school.
Ignores requests by persons in authority (e.g., bus driver, traffic warden, etc.).
Ridicules adults in authority (e.g., public figures).

THE CONDUCT DISORDER CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

PHYSICALLY AGGRESSIVE OR CRUEL 0 1 2 3

Often starts fight.
Uses physical force or a weapon to intimidate victim.
Physically aggressive if upset or annoyed.
Cruel to animals.
Cruel to people younger or weaker than himself or herself.
Enjoys cruel, sadistic, or violent films or games.
Talks aggressively or threatens violence.
Drives in an aggressive and dangerous manner.

DECEITFUL AND DISHONEST 0 1 2 3

Lies to adults.
Lies to peers.
Invents or exaggerates stories about himself, herself or others.
Breaks promises.
Steals from family or friends.
Steals from shops, school or other organizations.
Steals cars and drives them recklessly.
Breaks into premises and steals or vandalizes.
Forges parent’s signature.
Destroys documents that incriminate him or her (e.g., letter from school to parent).
Blames others and does not accept responsibility.
Incriminates others for his or her own advantage, makes false accusations.
Feigns ignorance when asked for truth.
Covers up for friends who are behaving inappropriately.

DRUG AND ALCOHOL ABUSE 0 1 2 3

Uses illegal drugs.
Deals in illegal drugs.
Drinks alcohol or smokes cigarettes while underage.
Drinks excessive alcohol.

THE CONDUCT DISORDER CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

DIFFICULT AT HOME 0 1 2 3
Often angry and uncooperative.
Secretive and often absent from home.
Particularly aggressive to a specific person (e.g., mother or younger sibling).
Demanding and intimidating, must have needs met.
Does not communicate positively.
Does not fulfill responsibilities.
Lacks warmth and empathy for family members.
Acts tough but is emotionally very immature.

FAMILY HISTORY YES NO DON’T KNOW

Other family members have behavioral or mental health problems

Additional comments and observations

THE OPPOSITIONAL DEFIANT CHECKLIST

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

DIFFICULT TO DISCIPLINE 0 1 2 3
Refuses to comply with reasonable requests.
Deliberately disobeys rules.
Finds loopholes in rules.
Does not seem to care if privileges or favorite things are removed.
Does not like to reveal that punishments are hurting.
Does not like to sow that they are pleased with rewards.
Becomes defiant and disobedient when criticized or punished.
Becomes aggressive and violent when criticized or punished.
Makes threats to try to stop adults disciplining him or her.
Blames others for his or her wrongdoings.
Highly indignant about own innocence if blamed.
Very persistent if ignored, will escalate behavior until adults responds.
Justifies behavior by saying rules, requests, etc., were unreasonable.

DIFFICULT TO PLEASE 0 1 2 3
Is unwilling to show pleasure in gifts or outings.
Spoils family trips by constant complaining.
Is reluctant to what he or she wants.
Does not want what is offered, wants something different.rejects what adults
thought would be a treat.
Changes preferences (asks for one thing and then rejects it when it is given).

ARGUES WITH ADULTS 0 1 2 3

Often says the opposite of what adults say.
Argues endlessly, even when obviously wrong.
Tries to make adult look at fault.
Says or does something and then denies it.

THE OPPOSITIONAL DEFIANT CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

LACK OF RESPECT FOR ADULTS 0 1 2 3

Uses body language and facial expressions to defy adults.
Scoffs at what adults say.
Talks about adults in disrespectful way.
Will not accept adult authority.
Plays adults off against one another.
Is very demanding of adults; expects them to accept orders.
Tries to manipulate others to undermine adults.

OFTEN DELIBERATELY ANNOYS PEOPLE 0 1 2 3

Deliberately annoys siblings or peers.
Openly defies rules when adults are watching.
Often tests limits.

EASILY ANNOYED 0 1 2 3
Is very touchy and easily annoyed.
Views simple accidents as deliberate provocations.
Gets very angry if siblings or peers retaliate to his or her provocation.
Is easily irritated if things do not work properly.
Is very sensitive (e.g., “hates” an everyday noise such as siblings sniffing).

ANGRY OR RESENTFUL 0 1 2 3
Loses temper very quickly over minor matters.
Takes general criticism very personally.
Sees personal accusations where none were intended.
Holds grudges for a long time.
Sulks for a long time after an upset.

SPITEFUL OR VINDICTIVE 0 1 2 3
Will deliberately spoil others’ fun.
Will retaliate in a spiteful or vindictive way.
Ridicules success or popularity in others.
Spoils surprises or secrets.

ASSOCIATED PROBLEMS 0 1 2 3
Has attention Deficit/ Hyperactivity Disorder.
Has learning difficulties.
Has communication difficulties.

THE OPPOSITIONAL DEFIANT CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

FAMILY HISTORY YES NO DON’T KNOW

Other family members have a history of Oppositional Defiant
Disorder.
Other family members have had behavioral or mental health
problems.
At least one parent is quiet and reclusive.

Additional comments and observations

THE LOW SELF-ESTEEM CHECKLIST

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

UNREALISTIC PERCEPTIONS ABOUT SELF 0 1 2 3

Often says negative things about himself or herself.
Sometimes exaggerates or fabricates stories to inflate his or her own image.
Does not expect to be liked.
Does not expect to succeed.

WEAK FOUNDATIONS FOR POSITIVE SELF- ESTEEM 0 1 2 3

Has learning difficulties.
Has social difficulties.
Is clumsy and poor at physical skills.
Comes from a family with low self-esteem.

NOT CONFIDENT WITH SCHOOLWORK 0 1 2 3

Is unwilling to try new things unless sure or success.
Does not initiate own learning.
Seldom takes on extra or more challenging tasks.
Does not volunteer answers in class.

DOES NOT COPE WELL WITH FAILURES 0 1 2 3

Often says “I don’t know” or “I can’t remember,” rather than make an error.
Gets upset if he or she loses.
Argues things are not fair when he or she loses.
Will not have another try once he or she has failed at something.
Attributes failures to bad luck.
Exaggerates failures when they do occur.
Is readily embarrassed.
Is reluctant to ask for help when in difficulty.
Devalues the success of others.

THE LOW SELF-ESTEEM CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

DOES NOT COPE WELL WITH SUCCESS 0 1 2 3

Brags and “goes over the top” when he or she has succeeded.
Is uncomfortable with praise or compliments.
Minimizes success when they do occur.
Attributes success to good luck.

FINDS IT HARD TO ACCEPT RESPONSIBILITY FOR OWN ACTIONS 0 1 2 3

Denies wrongdoing even when clearly at fault.
Unwilling to make decisions for himself or herself.
Gives credit to others when things go well.
Finds it difficult to apologize.

NEGATIVE PERCEPTIONS FROM OTHERS 0 1 2 3

Is frequently put down by siblings.
Is frequently put down by peers.
Is often put down by adults in family.
Is often put down by adults at school.
Is often a victim of teasing or bullying.

EASILY LED 0 1 2 3
Is anxious to follow peer group fads and fashions.
Is easily led by others.
Does not initiate activities.
Does not voice own opinion.

IMAGE IS VERY IMPORTANT 0 1 2 3

Tries to look tough.
Tries to maintain a “cool image”.
Tries to impress peers by acting clownish in school.
Acts tough even though unsure of himself or herself.
Relies on possessions to gain prestige.

DOES NOT HAVE POSITIVE FRIENDSHIPS 0 1 2 3

Tends to bully younger or weaker children.
Associates with peers who are unpopular with others.
Often tries to buy friendships.

EATING PATTERNS DISTURBED 0 1 2 3

Tries to improve image by extreme dieting.
Uses food for comfort.

THE LOW SELF-ESTEEM CHECKLIST (Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

Additional comments and observations

THE CHILD ABUSE CHECKLIST

(adopted from Glynis Hannell, BA (Hons.), MSc Registered Psychologist)
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

Student’s Name: _________________________________ Date: ______________ Age: _________

Name of person Completing checklist: ______________________________________________________
Relationship to Student: _________________________________________________________________

Direction: Each item that applies to the child or adolescent should be checked off using the following rating
scale.

0- Not at all, does not apply

1- Mild, sometimes observed, certainly applies
2- Moderate, often observed, certainly applies
3- Severe, frequently observed, strongly applies

EXPLICIT SEXUAL BEHAVIOR 0 1 2 3

Engages in sexually explicit play; makes sexually explicit comments, jokes, etc.
Sees a sexual meaning in everything.
Draws attention to own body or private parts.
Masturbates inappropriately.
Overly interested in bodily functions such as urination, menstruation, etc.
Develops a crush (with sexual overtones) on a teacher or older student.
Tells untrue stories about sexual encounters with unlikely people.
Seems uninhibited; will approach strangers inappropriately.

WITHDRAWN BEHAVIOR 0 1 2 3
Seems remote and “switched off”.
Seems sullen and uncommunicative.
Seems tired and unwilling to work or play.
Does not want to talk or write about himself or herself (e.g., will not write vacation
journal).
“Blocks” personal questions (e.g., “can’t remember” what he or she did during the
weekend).
Refuses or is anxious to go to school; does not want to leave parent.
Is secretive at home or at school.
Often wants to go to the medical room or be taken home.

SOCIAL DIFFICULTIES 0 1 2 3
Is overly possessive of one or two friends.
Rejects friendship when it is offered.
Tries to buy friends.
Is erratic; is friendly one day, unfriendly the next.
Is bad tempered and easily annoyed by small things.
Is verbally and physically aggressive when upset.

THE CHILD ABUSE CHECKLIST(Cont.)

 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora

DETERIORATION 0 1 2 3
Does worse schoolwork than previously.
Displays a more negative attitude toward learning.
Is less willing to take risks and is more anxious about failure.
Is less easygoing socially.
Takes less pride in self and achievements.
Is less well behaved than previously.
Changes eating patterns (eats too much or too little).
Has regressed to thumb sucking, soiling, bed wetting, etc.

MOODY, EMOTIONAL BEHAVIOR 0 1 2 3

Cries very readily.
Seems irritable and cranky.
Is unnecessary apologetic and ingratiating.
Makes poor eye contact.
Is very clingy to adult or special friend.
Wants a lot of reassurance.
Is obsessional (e.g., about cleanliness or neatness).
Seems angry and defiant.
Harms self (e.g., self-inflicted cuts, burns).
Engages in very risky behavior.
Attempts suicide.

SHOWS DISTRESS IN ARTWORK OR WRITING 0 1 2 3

Depicts angry, violent or tragic themes in artwork.
Produces very restrained, cautious, timid artwork.
Bases written stories on angry, violent, or tragic themes.
Produces sexually explicit drawings or stories.

PHYSICALLY INJURY 0 1 2 3
Has unexplained bruises, burns, etc.
Is unwilling to undress for swimming, physical education, etc.
Takes frequent days off school.
Makes frequent visit to the lavatory.
Has frequent urinary tract infections.

FAMILY HISTORY YES NO DON’T KNOW

Other family member has been abused.
Protection or supervision of child questionable.

THE CHILD ABUSE CHECKLIST (Cont.)

Additional comments and observations
 Republic of the Philippines
Region III
DIPACULAO NATIONAL HIGH SCHOOL
Dipaculao South
Mucdol, Dipaculao, Aurora