1

AFRAID OF NEW SITUATIONS………………………

0

1

2

3

4

5

6

7

8

9

10

 2

WORRIES TOO MUCH…………………………………

0

1

2

3

4

5

6

7

8

9

10

 3

SAD OR UNHAPPY MOST OF THE TIME…………

0

1

2

3

4

5

6

7

8

9

10

 4

SELF-CENTERED OR STUCK UP……………………

0

1

2

3

4

5

6

7

8

9

10

 5

POOR PERSONAL APPEARANCE……………………

0

1

2

3

4

5

6

7

8

9

10

 6

WASTES TIME…………………………………………

0

1

2

3

4

5

6

7

8

9

10

 7

OTHERS TAKE ADVANTAGE OF CHILD…………

0

1

2

3

4

5

6

7

8

9

10

 8

SHY OR TOO QUIET……………………………………

0

1

2

3

4

5

6

7

8

9

10

 9

IMMODEST ABOUT BODY, SHOWS OFF…………

0

1

2

3

4

5

6

7

8

9

10

10

SETS GOALS TOO HIGH………………………………

0

1

2

3

4

5

6

7

8

9

10

11

DENIES HAVING DONE WRONG……………………

0

1

2

3

4

5

6

7

8

9

10

12

TELLS THINGS THAT DID NOT OCCUR……………

0

1

2

3

4

5

6

7

8

9

10

13

CLINGS TO ADULTS……………………………………

0

1

2

3

4

5

6

7

8

9

10

14

RESTLESS SLEEP………………………………………

0

1

2

3

4

5

6

7

8

9

10

15

HAS TROUBLE FALLING ASLEEP……………………

0

1

2

3

4

5

6

7

8

9

10

16

CRIES OFTEN……………………………………………

0

1

2

3

4

5

6

7

8

9

10

17

SOILS SELF OR CLOTHING (URINATION OR BOWEL)

0

1

2

3

4

5

6

7

8

9

10

18

WETS THE BED…………………………………………

0

1

2

3

4

5

6

7

8

9

10

19

ACTS OLDER THAN ACTUAL AGE…………………

0

1

2

3

4

5

6

7

8

9

10

20

RESTLESS, OVERACTIVE………………………………

0

1

2

3

4

5

6

7

8

9

10

21

FEELINGS HURT EASILY………………………………

0

1

2

3

4

5

6

7

8

9

10

22

ACTS YOUNGER THAN ACTUAL AGE……………

0

1

2

3

4

5

6

7

8

9

10

23

POOR SELF-IMAGE……………………………………

0

1

2

3

4

5

6

7

8

9

10

24

TAKES CORRECTION POORLY………………………

0

1

2

3

4

5

6

7

8

9

10

25

BLAMES OTHERS FOR MISTAKES…………………

0

1

2

3

4

5

6

7

8

9

10

26

BAD RELATIONS WITH ADULTS……………………

0

1

2

3

4

5

6

7

8

9

10

27

HAS DEPRESSED ATTITUDE…………………………

0

1

2

3

4

5

6

7

8

9

10

28

HAS FREQUENT HEADACHES………………………

0

1

2

3

4

5

6

7

8

9

10

29

COMPLAINS OF ACHES AND PAINS………………

0

1

2

3

4

5

6

7

8

9

10

30

FEELS DEPRESSED A LOT……………………………

0

1

2

3

4

5

6

7

8

9

10

31

MAKES POOR GRADES IN SCHOOL…………………….

0

1

2

3

4

5

6

7

8

9

10

32

FIGHTS AT SCHOOL……………………………………….

0

1

2

3

4

5

6

7

8

9

10

33

DISCIPLINE PROBLEM AT SCHOOL…………………….

0

1

2

3

4

5

6

7

8

9

10

34

DOES NOT COMPLETE HOMEWORK…………………...

0

1

2

3

4

5

6

7

8

9

10

35

STEALS AT SCHOOL……………………………………...

0

1

2

3

4

5

6

7

8

9

10

36

GETS ANGRY EASILY…………………………………….

0

1

2

3

4

5

6

7

8

9

10

37

KEEPS ANGER TO SELF…………………………………..

0

1

2

3

4

5

6

7

8

9

10

38

DOES AS HE/ SHE PLEASES………………………………

0

1

2

3

4

5

6

7

8

9

10

39

STEALS FROM STORES, ETC……………………………..

0

1

2

3

4

5

6

7

8

9

10

40

BAD RELATIONSHIP WITH OTHER KIDS………………

0

1

2

3

4

5

6

7

8

9

10

41

HAS EXPLOSIVE TEMPER TANTRUMS………………...

0

1

2

3

4

5

6

7

8

9

10

42

BULLIES OTHER CHILDREN……………………………..

0

1

2

3

4

5

6

7

8

9

10

43

STEALS AT HOME…………………………………………

0

1

2

3

4

5

6

7

8

9

10

44

USES PROFANITY………………………………………….

0

1

2

3

4

5

6

7

8

9

10

45

ABUSES OBJECTS (FURNITURE, ETC.)…………………

0

1

2

3

4

5

6

7

8

9

10

46

INAPPROPRIATE SEXUAL BEHAVIOR…………………

0

1

2

3

4

5

6

7

8

9

10

47

USES TOBACCO (SMOKES, CHEW, ETC.)………………

0

1

2

3

4

5

6

7

8

9

10

48

USES ALCOHLIC BEVERAGES…………………………..

0

1

2

3

4

5

6

7

8

9

10

49

USES DRUGS (SPECITY________________________)

0

1

2

3

4

5

6

7

8

9

10

50

GANG INVOLVEMENT/ INTEREST……………………...

0

1

2

3

4

5

6

7

8

9

10

51

LACK OF PARENTAL SUPERVISION……………………

0

1

2

3

4

5

6

7

8

9

10

52

NEGLECT……………………………………………………

0

1

2

3

4

5

6

7

8

9

10

53

LACK OF ECONOMIC RESOURCES……………………..

0

1

2

3

4

5

6

7

8

9

10

54

EASILY DISTRACTED……………………………………..

0

1

2

3

4

5

6

7

8

9

10

55

LIKES SCHOOL……………………………………………..

0

1

2

3

4

5

6

7

8

9

10

56

EXHIBITS LEADERSHIP QUALITIES……………………

0

1

2

3

4

5

6

7

8

9

10

57

RESPONSIBLE, FOLLOWS RULES……………………….

0

1

2

3

4

5

6

7

8

9

10

58

CONSIDERATE, HELPFUL………………………………..

0

1

2

3

4

5

6

7

8

9

10

59

AFFECTIONATE……………………………………………

0

1

2

3

4

5

6

7

8

9

10

60

HAPPY GO LUCKY, PLAYFUL…………………………...

0

1

2

3

4

5

6

7

8

9

10

61

ENTERTAINS SELF WELL………………………………..

0

1

2

3

4

5

6

7

8

9

10

62

SAD/CRIES………………………………………………….

0

1

2

3

4

5

6

7

8

9

10

63

FEELS USELESS, HELPLESS……………………………...

0

1

2

3

4

5

6

7

8

9

10

64

SULKS AND POUTS……………………………………….

0

1

2

3

4

5

6

7

8

9

10

 65

WITHDRAWN/PERFERS BEING ALONE………………..

0

1

2

3

4

5

6

7

8

9

10

 66

MOODY/EMOTION SHIFT QUICKLY……………………

0

1

2

3

4

5

6

7

8

9

10

 67

NERVOUS, FEARFUL, ANXIOUS………………………...

0

1

2

3

4

5

6

7

8

9

10

 68

TOUCHY, RESENTS CRITICISM………………………….

0

1

2

3

4

5

6

7

8

9

10

 69

SHOW EMOTION…………………………………………...

0

1

2

3

4

5

6

7

8

9

10

70

BITES NAILS………………………………………………..

0

1

2

3

4

5

6

7

8

9

10

71

GIVES UP EASILY………………………………………….

0

1

2

3

4

5

6

7

8

9

10

72

ARGUES, CRITICIZES OTHERS…………………………..

0

1

2

3

4

5

6

7

8

9

10

73

CURSES, USE ABUSIVE LANGUAGE…………………...

0

1

2

3

4

5

6

7

8

9

10

74

CONS OTHERS/MANIPULATIVE………………………...

0

1

2

3

4

5

6

7

8

9

10

75

DEMANDS ATTENTION…………………………………..

0

1

2

3

4

5

6

7

8

9

10

76

RESENTS DISCIPLINE……………………………………..

0

1

2

3

4

5

6

7

8

9

10

77

SCRATCHES, CUTS OR HURTS SELF…………………

0

1

2

3

4

5

6

7

8

9

10

78

PLAYS WITH FIRE/ MATCHES…………………………..

0

1

2

3

4

5

6

7

8

9

10

79

DISTORTS THE TRUTH……………………………………

0

1

2

3

4

5

6

7

8

9

10

80

CONFUSED, RAMBLED SPEECH………………………

0

1

2

3

4

5

6

7

8

9

10

81

“BORROWS” WITHOUT PERMISSION…………………

0

1

2

3

4

5

6

7

8

9

10

82

MAKES UNUSUAL REPETITIVE MOVEMENTS……….

0

1

2

3

4

5

6

7

8

9

10

83

NERVOUS HABITS (SPECIFY_____________________)..

0

1

2

3

4

5

6

7

8

9

10

84

HITS, FIGHTS, ATTACKS OTHERS……………………

0

1

2

3

4

5

6

7

8

9

10

85

THREATENS TO HURT OTHERS………………………

0

1

2

3

4

5

6

7

8

9

10

86

MAKES FRIENDS EASILY………………………………...

0

1

2

3

4

5

6

7

8

9

10

87

PASSIVE, EASILY INFLUENCED………………………...

0

1

2

3

4

5

6

7

8

9

10

88

WILLING TO SHARE WITH OTHERS……………………

0

1

2

3

4

5

6

7

8

9

10

89

DEFENDS SELF……………………………………………..

0

1

2

3

4

5

6

7

8

9

10

90

FORMS CLOSE RELATIONSHIPS………………………...

0

1

2

3

4

5

6

7

8

9

10

91

VANDALIZES, DESTROYS OBJECTS……………………

0

1

2

3

4

5

6

7

8

9

10

92

USES WEAPONS (SPECIFY______________________)…

0

1

2

3

4

5

6

7

8

9

10

93

RUNS AWAY (#_______)…………………………………

0

1

2

3

4

5

6

7

8

9

10

94

SNIFFS PAINTS, SOLVENTS, GASOLINE, ETC…………

0

1

2

3

4

5

6

7

8

9

10

95

SMOKES MARIJUANA……………………………………

0

1

2

3

4

5

6

7

8

9

10

96

DEALS DRUGS……………………………………………..

0

1

2

3

4

5

6

7

8

9

10

97

FORGERY/ THEFT BY CHECK……………………………

0

1

2

3

4

5

6

7

8

9

10

98

AUTOMOBILE THEFT……………………………………..

0

1

2

3

4

5

6

7

8

9

10

99

IMPULSIVE………………………………………………….

0

1

2

3

4

5

6

7

8

9

10

100

HAPPY TO COME TO THE TIPTON HOME……………..

0

1

2

3

4

5

6

7

8

9

10

YES    

 NO

DESCRIPTION AND DATE OF ONSET

ALLERGIES……………………………………………

______

______

__________________________________________________________

ASTHMA   ……………………………………………

______

______

__________________________________________________________

DIABETES  ……………………………………………

______

______

__________________________________________________________

HEART PROBLEMS ……………………………           

______

______

__________________________________________________________

HEARING LOSS  ……………………………                 

______

______

__________________________________________________________

WHOOPING COUGH…………………………………

______

______

__________________________________________________________

SEIZURES………………………………………………

______

______

__________________________________________________________

MEASLES………………………………………………

______

______

__________________________________________________________

EAR TROUBLE…………………………                     

______

______

__________________________________________________________

FAINTING SPELLS ……………………………………

______

______

__________________________________________________________

DIPTHERIA ……………………………………………

______

______

__________________________________________________________

THROAT TROUBLE …………………………………

______

______

__________________________________________________________

CHICKEN POX………………………………………

______

______

__________________________________________________________

MUMPS ………………………………………………

______

______

__________________________________________________________

KIDNEY PROBLEMS …………………………………

______

______

__________________________________________________________

RHUMATIC FEVER…………………………………

______

______

__________________________________________________________

SMALL POX  …………………………………………

______

______

__________________________________________________________

HAY FEVER  …………………………………………

______

______

__________________________________________________________

INFANTILE PARALYSIS……………………………

______

______

__________________________________________________________

SCARLETT FEVER ……………………………………

______

______

__________________________________________________________

HIGH BLOOD PRESSURE…………………………     

______

______

__________________________________________________________

HYPERACTIVE/ADHD……………………………       

______

______

__________________________________________________________

ALCOHOLISM…………………………………………

______

______

__________________________________________________________

AIDS/HIV OR STD’S …………………………            

______

______

__________________________________________________________

TUBERCULOSIS………………………………………

______

______

__________________________________________________________

HEPATITIS A B C…………………………….               

______

______

__________________________________________________________

SEXUAL RELATIONS …………………………           

______

______

__________________________________________________________

ABORTION/S…………………………………………  

______

______

__________________________________________________________

INCESTUOUS RELATIONS ………………………...

______

______

__________________________________________________________

INTRAVENOUS DRUG USE………………………..

______

______

DATE OF LAST USE _______________________________________

HAS CHILD STARTED HER PERIOD YET? ………

______

______