| Second part Psychological Factors |
| Questions about anxiety |
Never |
Sometimes |
Frequent |
| Your child enjoys visits to doctors and hospitals (he/she likes these visits) |
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| Your child is confused at the present of many people (such as in a bus or in a shpopping center) |
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| Your child has excessive suspense for homework, school lessons, school |
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| Your child fears that something bad will happen to him/her (such as car accident) |
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| Your child feels in difficult position in the cases of your absence (he/she feels unhappy, requires reasons to be with you even it knows that is not permitted) |
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| Your child has anxiety about his/her parents’ health (he/she fears for accidents or disorder) |
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| Questions about depression indicative factors (dysthymia, attidute derangement) |
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| Your child has sleep problems (difficulties in falling asleep; wakes at night or very early in the morning) |
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| Your child feels guilty and it is ready to ask for excuse (does it feel bad when it makes somthing wrong? –Does it ask for excuse?) |
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| Your child crys for insignificant reasons or without visible cause |
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| Your child has concentration difficulties with homework or other tasks (crys without significant reasons) ? |
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| Your child says he/she feels tired and wants to rest (do you feel that this is an excuse?) |
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| Your child complains of tummy pain or other symptoms such as headache, palpitations, joint pain or dizziness etc.) |
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| Do you have difficulties in understanding what he/she thinks and feels |
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| Your child has no friends or it avoids contact with friends on occasions |
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| Your child is inattentive or daydreams |
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| Your child complains that you don’ t love him/her or that you don’t understand him/her |
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| Your child forgets tasks like homework or fails to follow instructions |
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| Your child feels worthless and inefficient (“I cant shop, study, or do my homework”) |
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| Your child fears or overreacts to specific items or situations (his reaction is unusual) |
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| Your child frequently misses school |
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| Your child has has difficulty in making decisions |
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| Your child overreacts if you scold or penalize him/her |
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| Questions about behavior |
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| Your child has problems with his/her teachers |
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| Your child quarrels with his school-friends |
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| Your child interferes in an aggravating way in the conversations of adults |
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| Your child has frequent accidents or injuries |
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| Your child is undisciplined or fails to observe set limits |
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| Does your child miss school without to informing you? |
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| Does your child takes items that belong to other children |
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| Does your child steal money from your home (such as your wallet)? Does your child take items without informing you? |
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| Is your child aggressive in words or actions? |
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| Is your child overactive - can’ t stay in one place? |
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| Is your child a fussy eater? |
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| Does your child find excuses to avoid his/her homework |
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| Does your child find excuses to avoid going to school? |
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