(80 Item Behavioral and Symptom Checklist)

Demitri Papolos, M.D.


Name of person filling out form (optional)____________________________.

Email address (optional)______________________________.


Gender_____Age (Yrs.)______(Mos.) ______Date of Birth___/___/_____

Checked off by:  Mother_____  Father_____  Other_______________.

My child was diagnosed  with bipolar disorder by __________________________ who is trained as a general psychiatrist_____ pediatrician_____

child psychiatrist_____ neurologist_____ other_______________________.




We need to establish that each child who participates in this survey meets criteria for bipolar disorder. To make this independent determination, we need to know what specific symptoms and behaviors your child has displayed.


My child has and/or had the following symptoms and/or behaviors (please check all that apply: Past, Current). For example, if your child did display excessive distress when separated from his/her parent in the PAST but not CURRENTLY, an X would only be placed under PAST.  If he/she continues to experience separation anxiety in the present, then both PAST and CURRENT would be selected with an “X”.










1) excessive distress when separated from family



2) frequently exhibits excessive anxiety or worry



3) has difficulty arising in the AM



4) is hyperactive and easily excited in the PM



5) has difficulty settling at night



6) has difficulty getting to sleep



7) sleeps fitfully



8) often awakens in the middle of the night



9) has night terrors



10) grinds teeth



11) wets bed



12) often craves sweet tasting foods



13) is easily distracted by extraneous stimuli



14) displays periods of extreme hyperactivity






15) demonstrates inability to concentrate at school



16) easily distracted during repetitive chores & lessons



17) frequently attempts to avoid homework assignments



18) has been diagnosed with a non-verbal learning disability



19) has poor handwriting



20) has periods of inflated self-esteem



21) often has difficulty organizing tasks



22) has difficulty making transitions



23) is extremely sensitive to textures of clothes, labels



24) is extremely sensitive to certain odors



25) focuses intently on subjects of interest



26) often complains of being bored



27) at times is easily excitable



28) has many ideas at once



29) often interrupts or intrudes on others



30) has periods of excessive and rapid speech



31) has exaggerated ideas about self or abilities



32) tells tall tales



33) experiences periods of self doubt and poor self-esteem



34) feels easily rejected



35) feels easily humiliated or shamed



36) refuses to be subordinated by others



37) exhibits extreme sensitivity to sound and noise



38) displays abrupt, rapid mood swings during the day



39) has frequent irritable mood states



40) has frequent silly, goofy, giddy mood states



41) displays precocious sexual curiosity



42) exhibits inappropriate sexual behaviors



43) often takes excessive risks



44) often has periods of low energy



45) often fidgets with hands or feet



46) has periods of high, frenetic energy



47) at times has decreased initiative



48) relentlessly pursues own needs






49) often loses temper



50) is often demanding



51) often argues with adults



52) often defies or refuses to comply with rules



53) often blames others for his/her mistakes



54) frequently lies



55) is frequently angered in response to limit setting



56) often has protracted, explosive temper tantrums



57) is often bossy towards others



58) has difficulty maintaining friendships



59) displays aggressive behavior toward others



60) has destroyed property intentionally



61) often curses viciously, uses foul language in anger



62) makes moderate threats to others or self



63) makes clear threats of violence to others or self



64) has made clear threats of suicide



65) has cut self with sharp objects or engaged in body piercing



66) is both fearful of and fascinated with gore and blood



67) is fearful of and fascinated by violent, horrific images



68) experiences auditory and/or visual hallucinations



69) is fearful of clowns



70) has difficulty estimating time



71) has concern with dirt or germs



72) has rituals to seek reassurance from other persons



73) often hoards or avidly seeks to collect objects or food



74) is intolerant of delays



75) complains of feeling hot despite neutral outside temp.



76) has complained about body temperature extremes



77) is very intuitive



78) is very creative



79) is viewed by others as a leader



80) has auditory processing or short-term memory deficit