CHILD BEHAVIOR CHECKLIST FOR AGES 1½-5

For office use only

Please print. ID #

CHILD’S First Middle Last PARENTS’ USUAL TYPE OF WORK, even if not working now. Please
FULL be specific — for example, auto technician, high school teacher, homemaker,
NAME laborer, lathe operator, shoe salesman, army sergeant.
CHILD’S GENDER CHILD’S AGE CHILD’S ETHNIC GROUP PARENT 1 (or MOTHER)
OR RACE TYPE OF WORK
TODAY’S DATE CHILD’S BIRTHDATE PARENT 2 (or FATHER)
TYPE OF WORK
Mo. Day Year Mo. Day Year
THIS FORM FILLED OUT BY: (print your full name)
Please fill out this form to reflect your view of the child’s
behavior, even if other people might not agree. Feel free to Your relation to child:
write additional comments beside each item and in the space Parent 1 Parent 2 Another
provided on page 2. Be sure to answer all items. (or Mother) (or Father) (specify):
Below is a list of items that describe children. For each item that describes the child now or within the past 2 months, please circle
the 2 if the item is very true or often true of the child. Circle the 1 if the item is somewhat or sometimes true of the child. If the item
is not true of the child, circle the 0. Please answer all items as well as you can, even if some do not seem to apply to the child.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

PY
0 1 2 1. Aches or pains (without medical cause; do not 0 1 2 30. Easily jealous

T LE
include stomach or headaches) 0 1 2 31. Eats or drinks things that are not food - don’t
0 1 2 2. Acts too young for age include sweets (describe): _______________
0 1 2 3. Afraid to try new things ____________________________________
0 1 2 4. Avoids looking others in the eye 0 1 2 32. Fears certain animals. situations, or places
0 1 2 5. Can’t concentrate, can’t pay attention for long (describe): ___________________________

O
0 1 2 6. Can’t sit still, restless, or hyperactive ____________________________________
N MP
0 1 2 7. Can’t stand having things out of place 0 1 2 33. Feelings are easily hurt
0 1 2 8. Can’t stand waiting; wants everything now 0 1 2 34. Gets hurt a lot, accident-prone

C
0 1 2 9. Chews on things that aren’t edible
0 1 2 10. Clings to adults or too dependent
0 1 2 11. Constantly seeks help
0 1 2 12. Constipated, doesn’t move bowels (when not
sick)
0
0
0
0
1
1
1
1
2
2
2
2
35.
36.
37.
38.
Gets in many fights
Gets into everything
Gets too upset when separated from parents
Has trouble getting to sleep
O A

0 1 2 39. Headaches (without medical cause)

0 1 2 13. Cries a lot 0 1 2 40. Hits others
0 1 2 14. Cruel to animals 0 1 2 41. Holds breath
S

0 1 2 15. Defiant 0 1 2 42. Hurts animals or people without meaning to

O

0 1 2 16. Demands must be met immediately 0 1 2 43. Looks unhappy without good reason
0 1 2 17. Destroys own things 0 1 2 44. Angry moods
0 1 2 18. Destroys things belonging to family 0 1 2 45. Nausea, feels sick (without medical cause)
or other children 0 1 2 46. Nervous movements or twitching
0 1 2 19. Diarrhea or loose bowels (when not sick) (describe): ___________________________
0 1 2 20. Disobedient ____________________________________
0 1 2 21. Disturbed by any change in routine 0 1 2 47.
Nervous, highstrung, or tense
0 1 2 22. Doesn’t want to sleep alone 0 1 2 48.
Nightmares
0 1 2 23. Doesn’t answer when people talk to them 0 1 2 49.
Overeating
0 1 2 24. Doesn’t eat well (describe): _______________ 0 1 2 50.
Overtired
0 1 2 51.
Shows panic for no good reason
D

0 1 2 25. Doesn’t get along with other children 0 1 2 Painful bowel movements (without medical
52.
0 1 2 26. Doesn’t know how to have fun; acts like a cause)
little adult 0 1 2 53. Physically attacks people
0 1 2 27. Doesn’t seem to feel guilty after misbehaving 0 1 2 54. Picks nose, skin, or other parts of body
0 1 2 28. Doesn’t want to go out of home (describe): ___________________________
0 1 2 29. Easily frustrated Be sure you answered all items. Then see other side.
Copyright 2000 T. Achenbach & L. Rescorla
ASEBA, University of Vermont 10%

www.ASEBA.org (12.3.21) UNAUTHORIZED COPYING IS ILLEGAL 11-21 Edition-601

 Please print your answers. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True
0 1 2 55. Plays with own sex parts too much 0 1 2 79. Rapid shifts between sadness and
0 1 2 56. Poorly coordinated or clumsy excitement
0 1 2 57. Problems with eyes (without medical cause) 0 1 2 80. Strange behavior (describe): _____________
(describe): ___________________________ ____________________________________
____________________________________ 0 1 2 81. Stubborn, sullen, or irritable
0 1 2 58. Punishment doesn’t change behavior 0 1 2 82. Sudden changes in mood or feelings
0 1 2 59. Quickly shifts from one activity to another 0 1 2 83. Sulks a lot
0 1 2 60. Rashes or other skin problems (without 0 1 2 84. Talks or cries out in sleep
medical cause) 0 1 2 85. Temper tantrums or hot temper
0 1 2 61. Refuses to eat 0 1 2 86. Too concerned with neatness or
0 1 2 62. Refuses to play active games cleanliness
0 1 2 63. Repeatedly rocks head or body 0 1 2 87. Too fearful or anxious

PY
0 1 2 64. Resists going to bed at night 0 1 2 88. Uncooperative

T LE
0 1 2 65. Resists toilet training (describe): __________ 0 1 2 89. Underactive, slow moving, or lacks energy
____________________________________ 0 1 2 90. Unhappy, sad, or depressed
0 1 2 66. Screams a lot 0 1 2 91. Unusually loud
0 1 2 67. Seems unresponsive to affection 0 1 2 92. Upset by new people or situations
0 1 2 68. Self-conscious or easily embarrassed (describe): ___________________________

O
____________________________________
N MP
0 1 2 69. Selfish or won’t share
0 1 2 70. Shows little affection toward people 0 1 2 93. Vomiting, throwing up (without medical
cause)
0 1 2 71. Shows little interest in things around them
0 1 2 94. Wakes up often at night

C
0 1 2 72. Shows too little fear of getting hurt
0 1 2 73. Too shy or timid
0 1 2 74. Sleeps less than most kids during day
and/or night (describe): _________________
0 1 2 95. Wanders away
0 1 2 96. Wants a lot of attention
0 1 2 97. Whining
O A

____________________________________ 0 1 2 98. Withdrawn, doesn’t get involved with others

0 1 2 75. Smears or plays with bowel movements 0 1 2 99. Worries
0 1 2 76. Speech problem (describe): ______________ 100. Please write in any problems the child has
S

that were not listed above.

O

____________________________________
0 1 2 ____________________________________
0 1 2 77. Stares into space or seems preoccupied
0 1 2 ____________________________________
0 1 2 78. Stomachaches or cramps (without medical
cause) 0 1 2 ____________________________________
Please be sure you have answered all items.
Underline any you are concerned about.
Does the child have any illness or disability (either physical or mental)? No Yes Please describe:

What concerns you most about the child?

D

Please describe the best things about the child:

PAGE 2
 LANGUAGE DEVELOPMENT SURVEY FOR AGES 18-35 MONTHS For office use only
ID #

The Language Development Survey assesses children’s word combinations and vocabulary. By carefully
completing the Language Development Survey, you can help us obtain an accurate picture of the child’s
developing language. Please print your answers. Be sure to answer all items.

I. Was the child born earlier than the usual 9 months after conception?
No Yes - how many weeks early? _______ weeks early.

II. How much did the child weigh at birth?___________ pounds __________ ounces; or __________ grams.

III. How many ear infections did the child have before age 24 months?
0-2 3-5 6-8 9 or more

PY
T LE
IV. Is any language besides English spoken in the child’s home?
No Yes - please list the language(s):

O
V. Has anyone in the child’s family been slow in learning to talk?
N MP
No Yes - please list their relationship to the child; for example, brother, father:

C
VI. Are you worried about the child’s language development?
No Yes - why?
O A

VII. Does the child spontaneously say words in any language (not just imitates or understands words)?
S
O

No Yes - if yes, please complete item VIII and page 4.

VIII. Does the child combine 2 or more words into phrases? For example: “more cookie,” “car bye-bye.”

No Yes - please print 5 of the child’s longest and best phrases or sentences.
For each phrase that is not in English, print the name of the language.

1.

2.
D

3.

4.

5.

Be sure you answered all items. Then see other side.

PAGE 3
Please circle each word that the child says SPONTANEOUSLY (not just imitates or understands). If your child says
non-English versions of words on the list, circle the English word and write the first letter of the language (e.g., S for
Spanish). Please include words even if they are not pronounced clearly or are in “baby talk” (for example: “baba” for
bottle).
FOODS ANIMALS ACTIONS HOUSEHOLD MODIFIERS OTHER
1. apple 55. bear 107. bath 163. bathtub 216. all gone 264. any letter
2. banana 56. bee 108. breakfast 164. bed 217. all right 265. away
3. bread 57. bird 109. bring 165. blanket 218. bad 266. booboo
4. butter 58. bug 110. catch 166. bottle 219. big 267. byebye
5. cake 59. bunny 111. clap 167. bowl 220. black 268. excuse me
6. candy 60. cat 112. close 168. chair 221. blue 269. here
7. cereal 61. chicken 113. come 169. clock 222. broken 270. hi, hello
8. cheese 62. cow 114. cough 170. crib 223. clean 271. in
9. coffee 63. dog 115. cut 171. cup 224. cold 272. me
10. cookie 64. duck 116. dance 172. door 225. dark 273. meow
11. crackers 65. elephant 117. dinner 173. floor 226. dirty 274. my
12. drink 66. fish 118. doodoo/poop 174. fork 227. dry 275. myself
13. egg 67. frog 119. down 175. glass 228. good 276. nightnight

PY
14. food 68. horse 120. eat 176. knife 229. happy 277. no
15. grapes 69. monkey 121. feed 177. light 230. heavy 278. off

T LE
16. gum 70. pig 122. finish 178. mirror 231. hot 279. on
17. hamburger 71. puppy 123. fix 179. pillow 232. hungry 280. out
18. hotdog 72. snake 124. get 180. plate 233. little 281. please
19. ice ceam 73. tiger 125. give 181. potty 234. mine 282. Sesame St.
20. juice 74. turkey 126. go 182. radio 235. more 283. shut up
21. meat 75. turtle 127. have 183. room 236. nice 284. thank you

O
22. milk 128. help 184. sink 237. pretty 285. there
BODY PARTS 129. hit
N MP
23. orange 185. soap 238. red 286. under
24. pizza 76. arm 130. hug 186. spoon 239. stinky 287. welcome
25. pretzel 77. belly button 131. jump 187. stairs 240. that 288. what
26. raisins 78. bottom 132. kick 188. table 241. this 289. where
27. soda
28. soup
C
29. spaghetti
30. tea
31. toast
79. chin
80. ear
81. elbow
82. eye
83. face
84. finger
133. kiss
134. knock
135. look
136. love
137. lunch
189. telephone
190. towel
191. trash
192. T.V.
193. window
242. tired
243. wet
244. white
245. yellow
246. yucky
290. why
291. woofwoof
292. yes
293. you
294. yumyum
O A

32. water 138. make PERSONAL CLOTHES 295. any number

85. foot 139. nap
TOYS 86. hair 140. open 194. brush 247. belt PEOPLE
33. ball 87. hand 141. outside 195. comb 248. boots 296. aunt
88. knee 196. glasses 249. coat 297. baby
S

34. balloon 142. pattycake

O

35. blocks 89. leg 143. peekaboo 197. key 250. diaper 298. boy
36. book 90. mouth 144. peepee 198. money 251. dress 299. daddy
37. crayons 91. neck 145. push 199. paper 252. gloves 300. doctor
38. doll 92. nose 146. read 200. pen 253. hat 301. girl
39. picture 93. teeth 147. ride 201. pencil 254. jacket 302. grandma
40. present 94. thumb 148. run 202. penny 255. mittens 303. grandpa
41. slide 95. toe 149. see 203. pocketbook 256. pajamas 304. lady
42. swing 96. tummy 150. show 204. tissue 257. pants 305. man
43. teddy bear 151. shut 205. tooth brush 258. shirt 306. mommy
VEHICLES 152. sing 206. umbrella 259. shoes 307. own name
OUTDOORS 97. bike 153. sit 207. watch 260. slippers 308. pet name
98. boat 154. sleep 261. sneakers 309. uncle
44. flower PLACES 262. socks 310. name of TV
45. house 99. bus 155. stop
100. car 156. take 208. church 263. sweater or story
46. moon character
47. rain 101. motorcycle 157. throw 209. home
D

48. sidewalk 102. plane 158. tickle 210. hospital

49. sky 103. stroller 159. up 211. library Other words your child says,
50. snow 104. train 160. walk 212. park
105. trolley 161. want 213. school including non-English words:
51. star
52. street 106. truck 162. wash 214. store
53. sun 215. zoo
54. tree

PAGE 4