740 Assessment MeasuresParent/Guardian-Rated DSM-5 Level 1 Cros s-Cutting Symptom Measure—Child Age 6–17
Child’s Name:__________________________________________ ___ Age: __________ Sex: [ ] Male [ ] Female Date:_____________
Relationship to the child:  ___________________________________
Instructions  (to parent or guardian of child): The questions below ask about things that might have bothered your child. For each question, circle the number that 
best describes how much (or how often) your child has been bothered by each problem during t he past TWO (2) WEEKS.
During the past TWO (2) WEEKS,  how much (or how often) has your 
child…None
Not at 
allSlight
Rare, less than 
a day or twoMild
Several 
daysModerate
More than 
half the daysSevere
Nearly 
every dayHighest 
Domain Score  
(clinician)
I. 1.Complained of stomachaches, headaches, or other aches and 
pains?0 1 2 3 4
2.Said he/she was worried about hi s/her health or about getting 
sick?0 1 2 3 4
II. 3. Had problems sleeping—that is, trouble falling asleep, staying 
asleep, or waking up too early?01 23 4
III. 4.Had problems paying attention when he/she was in class or 
doing his/her homework or read ing a book or playing a game?0 1 2 3 4
IV. 5. Had less fun doing things than he/she used to? 0 1 2 3 4
6. Seemed sad or depressed for several hours? 0 1 2 3 4
V.
 and