s e r d a P

Minors
PS
2- Age 6 - 11

Nombre del menor: _______________________________________ Your name:_____________________________________________

Fecha:__________________ Fecha de nacimiento:______________ Su género:____Masculino ____Femenino
Escuela:_________________________________ Grado:_________ Su relación con el menor: ____ Madre ____ Padre ____ Tutor
Género del menor: ____Masculino ____Femenino Edad:________ ____ Other:_________________________

Do you have any concerns regarding the following aspects:

a. Vision? Y N ________________________________
b. Are you listening? Y N ________________________________

c. Eating habits? Y N ______________________

Instructions How to mark your answers

This form contains phrases that describe how children Make sure to circle the letter you choose
they act. Please read each sentence and select the answer that
Describe how your son/daughter has behaved recently (in the N A S C
last months)
If you wish to change your answer, mark an X over it and
Select if the behavior NEVER occurs circulate the new option, as presented below:
Select this behavior SOMETIMES occurs
Select if the FOLLOWED behavior occurs N A S C
Select if the behavior ALMOST ALWAYS occurs

Please make sure to answer ALL statements. Yes

you are not sure of your answer, select the answer that Before starting, make sure to complete the information that
the closer it gets. A response of 'Never' does not mean that your is found above the instructions.
son/daughter never develops that behavior, but you do not have
the knowledge that this occurs.
 N = Never A = Sometimes S = Followed C = Almost Always

1. Pay attention N A S C 56. Is able to follow the information N A S C

2. Make positive comments about others N A S C 57. Vomits N A S C
3. Disobey N A S C Confuses reality with fantasy N A S C
4. He/She gets angry easily. N A S C 59. Manipulates others N A S C
Responds inappropriately when he/she It is sad N A S C
5. N A S C
he/she asks a question 61. Answer the phone appropriately N A S C
6. Gets sick N A S C It is good at making people
62. N A S C
7. He/She gets into trouble N A S C work well together
8. He/She has good coping skills N A S C 63. Expresses fear of getting sick N A S C
9. He/She is worried N A S C He/She has trouble buttoning up the buttons.
64. N A S C
10. Avoid eye contact N A S C or dressing up
11. It has a short attention span N A S C It is cruel to animals. N A S C
12. Act confusingly N A S C He/She needs to be reminded to brush his/her teeth.
66. N A S C
13. He/She is fond of food N A S C teeth
Say 'Please' and 'Thank you' N A S C He is worried about what the parents N A think.
S C
He complains about his health N A S C Break the rules N A S C
Plan well N A S C He has difficulty explaining the rules of
69. N A S C
It looks strange. N A S C games
18. Does things on their own initiative N A S C He gets angry easily. N A S C
Has accidents going to the bathroom N A S C 71. Do the work step by step N A S C
20. Say 'I think I am sick.' N A S C 72. Trips or falls easily N A S C
He/She is fearful. N A S C Has little self-control N A S C
22. Choose healthy food N A S C 74. Break the rules just to see N whatA Shappens
C
23. Lie N A S C Sleeps with the parents N A S C
24. Act without thinking N A S C 76. Communicates clearly N A S C
25. Blames herself for everything N A S C 77. Congratulate others N A S C
26. Loses control when angry N A S C 78. He/She has headaches N A S C
27. Has difficulty following routines N A S C 79. Reacciona negativamente N A S C
28. Listen to instructions N A S C I have no friends N A S C
29. He is usually chosen as a leader N A S C 81. It is shown to be out of touch withN reality A S C
30. Presents repetitive movements N A S C 82. My bed N A S C
You seem tense N A S C 83. Listen carefully N A S C
32. He/She is too active. N A S C He/She is nervous. N A S C
Take notes correctly N A S C Having trouble obtaining the information
85. N A S C
Cries easily N A S C when it is needed
35. Threatens to hurt others N A S C 86. Accept things as they are N A S C
36. Avoid exercise or physical activity N A S C Quickly joins group activities. N A S C
37. Realistic goals are proposed N A S C He stays "out of it" N A S C
Worries about things that she cannot 89. Starts fires N A S C
38. N A S C
change 90. Gather your things N A S C
He complains of being sick without N being A S so.
C Easily distracted N A S C
40. Changes mood quickly N A S C 92. Recovers quickly after a discussion N A S C
He breaks or throws things when Nhe'sA angry S C 93. Play with things while eating N A S C
Interrupts others when they are Makes others feel bad N A S C
42. N A S C
talking 95. Find out how to solve problems N A S C
43. Lies to others N A S C Avoid other children N A S C
He exaggerates his reactions to situations 97. Makes others feel welcome N A S C
44. N A S C
stressful 98. Hits other children N A S C
He says 'I hate myself' N A S C 99. It is in constant motion N A S C
He is careless with his belongings. N A S C 100. It is lonely N A S C
It adjusts well to changes in plans. It is painful with adults N A S C
47. N A S C 102. He/She likes to talk about his/her day.
relatives N A S C
He/She is shameful with other children N A S C 103. It adapts well to changes N A S C
49. Complains of pain N A S C 104. Say "It's my fault" N A S C
Bothers others N A S C 105. He/She has a fever N A S C
51. Eats things that are not food N A S C 106. Respond to others N A S C
Says 'I want to die' or 'I wish I were here' He cares about what his teacher thinks.N A S C
52. N A S C
dead It bothers children who are different from
108. N A S C
53. Show interest in the ideas of N others
A S C he/she
54. He/She cares about what other Nchildren
A S think
C 109. Start the conversations N A S C
55. Hurt others on purpose N A S C He/She is negative. N A S C
 N = Never A = A veces S = Followed C = Almost Always
111. Has trouble making new friends N A S C Acts out of control N A S C
112. He says, 'I'm not good at this.' N A S C Shows incoherent feelings with the
167. N A S C
Help others to be better N A S C situation
114. Interrupts the activities of other children
N A S C 168. It is not clear when presenting ideas. N A S C
Acts strangely N A S C 169. It is resilient N A S C
116. Says "I can't do anything right" N A S C 170. Prefers to play alone N A S C
117. Annoys others N A S C 171. Does strange things N A S C
Complains about physical problems N A S C 172. You can't wait for your turn N A S C
He/She gets irritated easily. N A S C 173. You are motivated to excel N A S C
Give good suggestions to solve Congratulate others when good things happen.
120. N A S C 174. they happen to them N A S C
problems
Discuss when things are not to your liking. 175. Has trouble concentrating N A S C
121. N A S C
way
122. Says things that don't make sense N A S C
123. Overcomes the problems N A S C General Comments
I want to kill myself N A S C
Act as if the other children do not What are the strengths in behavioral and emotional of your
125. N A S C
they were son/daughter?
126. He/She distances himself/herself from others N A S C
127. Pay attention when speaking to them N A S C
128. He is worried about making mistakesN A S C
Nobody loves me N A S C
130. Handle losing and winning well N A S C
Vomits after eating N A S C
Complains of stomach pain N A S C
133. He/She is easy to please N A S C
134. Accept people who are different N A S C
135. He/She is easy to calm down when he/she gets Nangry.
A S C
136. Has panic attacks N A S C
137. Offers help to other children N A S C
138. It's too emotional N A S C
Show the basic emotions in a way
139. N A S C
clear
140. He/She has attacks N A S C
141. Lies to get out of trouble N A S C
142. Make decisions easily N A S C
143. Adapts well to new teachers N A S C
144. Items N A S C Por favor enliste alguna preocupación que tenga sobre su hijo/a en
145. Does strange things N A S C relation to your behavior or emotionally.
He/She is too aggressive. N A S C
He/She gets stressed easily N A S C
It is clear when sharing their experiences
148. N A S C
personal
Organize your tasks or activities of
149. N A S C
appropriate way
150. Lies about others N A S C
He is unable to 'lower the pace.' N A S C
152. Seems to not perceive others N A S C
Act safely N A S C
Encourage others to give their best. N A S C
155. Prefers to be the leader N A S C
156. Avoid making friends N A S C
157. Talk to yourself N A S C
158. His speech is confusing or disorganized.N A S C
Interrupts his parents when they are at
159. N A S C
telephone
160. Says 'I am afraid of making a mistake' N A S C
He/She is afraid of getting sick. N A S C
162. Escape from home N A S C
Makes friends easily N A S C
164. Spy on others N A S C
165. He is able to describe his feelingsN A S C