Please answer every question.
Over the past 6 months or more, how often have you noticed or been concerned about any of the following statements in your child?
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Almost Never
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Sometimes
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Often
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Very Often
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| 1: My child is preoccupied by recurrent thoughts, images, impulses, fears or desires that are not as a result of real life problems or worries |
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| 2: My child is preoccupied by these recurrent thoughts, images, impulses, fears or desires for more than 1 hour per day |
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| 3: These recurrent thoughts, images, impulses, fears or desires distress my child, are a cause of concern and may disrupt his or her performance at school, daily activities or ability to function optimally |
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| 4: My child attempts to ignore, suppress or override these recurrent thoughts, images, impulses, fears or desires with mental strategies or techniques to distract themselves |
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| 5: My child performs repetitive rituals or routines, such as hand washing or constant cleaning, repeated checking/ ordering/counting, repeating a task/sound/word/number or action until it is “just right,” or rigidly following self-imposed rules |
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| 6: My child performs these repetitive rituals or routines to help him- or herself unwind, relax or prevent bad things from happening |
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| 7: My child spends more than 1 hour per day performing these repetitive rituals or routines |
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| 8: My child becomes easily stressed, anxious or agitiated if he or she is prevented from performing these repetitive rituals or routines |
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| 9: I or others believe that these repetitive thoughts or rituals my child performs are excessive, awkward, odd or extreme |
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| 10: My child’s repetitive thought patterns or deeds tend to interfere or have a negative impact on his or her life, academics, social/leisure activities or relationships |
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