FttlTl.

'", NOTOBTAIruEO
INFORMATION I (UseInformationProviderNumber(
from the InformationProviderpage)
Function.l llutFmr in mc.ru.ing Roldt
Ust all the informationproviderspresent:
in the lastweekpresenP n Yes f} Ho f] Unknown
Wastheprimarycaregir,er

Scalefor Children(EESC)
TheEmotionExpression
!::

Readeachstatementcarefullyand checkor tick'"$

basedonthe past:
(4 theboxwithyourresponse
tuo weeks.Thereare no right or wronganswers.
1.Mychilddoesnot talk enough T n T T f,
2. My child'smood is flat T n I T LJ

3. Mychildhassparklein his/herpersonality n T I T T
4. Mychildseemshappy n n n I l
t--I
t

5. Mychildgetsupseteasily I I I
n T n
6. Mychildseemseasygoing n T_l
t t l T LJ
7. Mychild'spersonalityhasblossomed n n n n t l

8. Mychild'spersonalityseems'danlpened" n n n r LI

9.Mychildisoutgoing l n l T TI
t_J

10.Mychildseemsdown f n f n n
11.Mychildjustdoesn'tseemto be him/herself n n T n_____!
12Mychildsta)rstohim/herself T-t
t l
T-l
l l T r - r '
t
U
l

TI
13.Mychildisteafful f U T l l l l

14.Mychild'strue personalitycomesthrough t
LJ
l t-t
L---J T n T
15.Mychildissluggish T t
U
l
T n T
16.Mychildzonesout u n r n r
17.Mychildlackshis/herspark . T T TI
L' tr n
18.Mychildis initableor cranky I
U
I \
n n L.J T
19.Mychildshowsa rangeof emotions n u f n l
towardslife
20.Mychildis enthusiastic n n n T n
21.Mychildisfriendly n n
U f n LI

22. Mychild's emotions seem flat l n T n n

23.Mychildhasmoodswings u n [ . I n
24.Mychildis spontaneous ,"fl,: n
U f, n
l l l l

25.Mychildis overlysensitive n n I L-J l

26. My child is affectionate T n t
I
l
I n n
27.Mychildisfunny u n l l l I
28.Mychildis creative n n T T T
29. My child is confident n T n f l l

Copyrighl@ 2006Untuersityof Nebraska

I
foi iermissionto usethe scatelree of charge,pleasocontac*Dr.ChrisKratochMl, '
Universityof NebraskaMJol C"nt"r' ckitocir@unmc'edu
g&
ATNRS00248_Sep_2013

- - -
F*SJil!-;,;
(GIPD)
The Global lmpression of Perceived Difficulties scale

1. Think about the Past seven

days. How difficult have the
mornings of your child been?
Pleasetakeinto account all
information you maYhave
obtainedfrom personswho
have also seen your child in the
morning.
2. Think about the Past seven
days. How difficutt has the time
spent in school been for Your
child?
Pleasetakeinto accountall
information you may have obtained
ilil
from persons who know Your child
(e.g.parents,teachers,nurses'
other caregivers).
3. Think about the Past seven
days. How difficult has the time
spent doing homeworkbeen for
your child?
Pleasetakeinto account all
information you may also have
obtainedfrom Personswho know
your child (e.g.parents,teachers,
nurses,other caregivers).
4. Think aboutthe Past seven
days. How diflicult have the
evenings of your child been?
Pleasetake into account all
information you maYhave
obtained from Personswho
have also seen Your child in the
evening.
5. Think about the Past seven
days. How difiicult have the
days and nights of Your child
been generallY?
Pleasetake into account all
information you may have
obtainedfrom other Persons
who also know Yourchild (e'9.
parents,teachers,nurses,other
caregivers).

PhD,Ralfw. Diamar,r,ud pnu ManfredDopfrer' PhD

copyright@peterM. WehmeierMD*,Alexanderschacht
ZOO!
Elililly andCompanty'
MedicalDepanment'BadHomburg'Germany'
LillyDeutschland,

lffifluHF'

ATNRS0O249-SeP-2013 itli::=j-.:*;r::1.;r:i;:::. .
 H.g.m-ffi Yournarne:

Rdalionshipto cfrild:

TheWeissFunctionallmpairmentRatingScale- ParentRepor
(wFtRS-P)

1.Hadrgproblems
wi&rbro8rers&si$ers
problemsbetweenparents
2. Causing
3.Takestime awayftomfamily members'nork or acfivities
4. Causingfighting in the family
5. lsolatingthe familyftom fbnds and socialactivities
6. Makesit hardfor the familyto havefun together
7. Makesparenting difficult
8. Makesit hardto givefair attentionto all familymembers
9. Provokes
othersto hit or screamat hidrlher
10.Coststhefamilymore money

Learnlng
L Makesit difficult to keepup with schoolwork
2, Needsextrahelpaf school
3.Needs
tutoring
4. Receives
gradesthat are not asgood ashislherability nla
Behaviour
problemsfur the tecfier in the dassroom
1.Causes
2. Receives'time-out"
or removalftom the classroorn . 0
3. Havingproblemsin the schoolyard
4. Receives
detentions(duringor after schoot) nla
5.Suspended
or expelledfrom scfrool nla
Missesdassesor is late for school

1.Excessive
useof TV,computer,or videogames
2. Keepingdean,brushingteeth, brushinghair,bathing,etc ,

3. Problemsgetting readyfor scftool

4, Problemsgetting readyfor bed
5, Problemswith eating (pickyeater,jirnk food)
6. Problemswith sleeping
7.Getshurtor injured
8. Avoidsexercise 0 '
9. Needsmore medicalcare t 1

10.Hastroubletakingmedication,getting needles
or visitingthe doctor/dentist
''la "
ffiFgffi*r+:.:1 r
 HAmffi Yournane:
Rdionship todrild:

Cirde fie nusrberbr $e

cb{rlis

1.Wdtild bds bad&ut himselflhersetf nla

2. W cfiild doesnot haveenoughfun nla
3. Mychildis not happywith his/herlife nla

1. Beingteasedor bulliedby other children nla

2. Teases
or bulliesother ctrildren nla
3. Prcblemsgetting along with other children nla
4. Ptoblemsparticipatingin after-scfroolactivities (sports,
music,clubs) nla
5. Problemsmakingnew ftiends nla
. 6, Probfemskeepingfriends nla
7. Difficulty with parties (not invited, avoids them, misbehaves) nla

1.Easilyled by other cfrildren(peerpressure)

2. Breaking
or damaging
things
3. Doingthingsthat are itiegal nla
4. Beinginvolvedwith the police nla
5. Smokingcigarettes nla
6. Takingillegatdrugs nla
7. Doingdangerousthings nla
8.Causes
injuryto others nla
9. Saysmeanor inappropriatethings nla
10.Sexually
inappropriate
behaviour

ScgBilA
1.Number of itemsscored2 or 3
' o ! ,/' :
2.Totalscore
or
3.Meanscore

@universltyof Bd[slr Cdumbia frll. lny part d hb docurnentmay be fieely reproducedlvithout obtainingthe permlssinnof the copyright
orvner,prwiled ftat no dtarqress'hatsoe\rerate m* to the text ald proviied that this oipyrptrt noticeb-irduded in its entirety in any and
all copicsofthb document.

ATNRS00247-Sep_2013 ,*fu