About this template
The Pediatric Symptom Checklist (PSC-17) is a widely used screening tool designed to help pediatricians, mental health providers, and childcare specialists assess children's cognitive, emotional, and behavioral health. This template allows parents, guardians, or primary caregivers to quickly complete the 17-item standardized checklist prior to an appointment or telehealth consultation, streamlining clinical intake and enabling more focused diagnostic conversations.
By gathering structured responses regarding attention, internalizing, and externalizing behaviors, healthcare providers can identify potential developmental or psychological concerns early. Utilizing Doc2Form enables clinics to effortlessly deploy this assessment as an online Google Form, ensuring results are instantly organized and easy to review before seeing the patient.
Key features
- Standardized 17-item symptom frequency rating scale.
- Collect caregiver and child details in a single submission.
- Streamline telehealth intake and pre-visit preparations.
- Easily review and organize responses in a connected spreadsheet.
- Mobile-friendly format for convenient completion by parents on any device.
Use cases
- Pre-visit screening for pediatric wellness checks.
- Initial intake assessments in child psychology and counseling practices.
- Behavioral health tracking during pediatric telehealth consultations.
- School nursing and student health evaluations.
What this form collects
- Caregiver Full Name (Short answer)Enter your first and last name.
- Date of Completion (Date)Select today's date.
- Child Full Name (Short answer)Enter the child's first and last name.
- Child Date of Birth (Date)Enter the child's date of birth.
- Fidgety, unable to sit still (Multiple choice)Consider typical behavior compared to peers.
- Daydreaming too much (Multiple choice)Frequently distracted or lost in thought.
- Easily distracted (Multiple choice)Difficulty maintaining focus on tasks.
- Ablaze or trouble concentrating (Multiple choice)Struggles to complete schoolwork or chores requiring focus.
- Acts as if driven by a motor (Multiple choice)Constantly on the go or overly energetic.
- Feels sad, unhappy, or depressed (Multiple choice)Expresses feelings of sadness or low mood.
- Is hopless or lacks motivation (Multiple choice)Expresses a negative outlook on the future.
- Is down on self or feels worthless (Multiple choice)Self-critical or expresses low self-esteem.
- Worries a lot (Multiple choice)Expresses anxiety about everyday situations or the future.
- Seems to be having less fun (Multiple choice)Loss of interest in hobbies or activities previously enjoyed.
- Fights with other children (Multiple choice)Shows verbal or physical aggression toward peers or siblings.
- Does not listen to rules (Multiple choice)Defies authority figures, parents, or teachers.
- Does not understand other people's feelings (Multiple choice)Lacks empathy or has difficulty recognizing others' emotions.
- Teases others or is mean (Multiple choice)Engages in bullying or mean-spirited behavior.
- Blames others for troubles (Multiple choice)Refuses to take responsibility for own mistakes.
- Takes things that do not belong (Multiple choice)Steals or appropriates items without permission.
- Refuses to share (Multiple choice)Unwillingness to share toys, supplies, or personal items with others.
- Additional Comments or Concerns (Paragraph)Please share any additional details regarding your child's behavior, health, or recent changes.
FAQ
What is the Pediatric Symptom Checklist (PSC-17)?
The PSC-17 is a brief, validated screening tool used by healthcare providers to identify emotional and behavioral problems in children and adolescents.
Who fills out this form?
The form is typically completed by the child's parent, legal guardian, or primary caregiver who is familiar with the child's daily behaviors.
How can I customize this form for my clinic?
With Doc2Form, you can instantly convert or edit this template in Google Forms to add your clinic's branding, specific intake questions, or follow-up instructions.
Are the responses saved securely?
Yes, all form submissions are stored securely in your Google Drive account, allowing you to manage access permissions according to your practice's privacy protocols.
Can parents complete this form on their mobile phones?
Yes, Google Forms automatically adapts to mobile devices, making it easy for caregivers to fill out the checklist from a smartphone or tablet before their appointment.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.