Gagandeep Singh, M.D., LLC

YMRS - PARENT VERSION

Full Name *

Please read each question below and select the answer number which most closely describes your child.

Mood - Is your child’s mood higher (better) than usual?

No

Mildly or possibly increased

Definite elevation - more optimistic, self-confident, cheerful; appropriate to their conversation

Elevated but inappropriate to content; joking, mildly silly

Euphoric; inappropriate laughter; singing/making noises; very silly

Motor Activity/Energy - Does your child’s energy level or motor activity appear to be greater than usual?

No

Mildly or possibly increased

More animated; increased gesturing

Energy is excessive; hyperactive at times; restless but can be calmed

Very excited; continuous hyperactivity; cannot be calmed

Sexual Interest - Is your child showing more than usual interest in sexual matters?

No

Mildly or possibly increased

Definite increase when the topic arises

Talks spontaneously about sexual matters; gives more detail than usual; more interested in girls/boys than usual

Has shown open sexual behavior - touching others of self inappropriately

Sleep - Has your child’s sleep decreased lately?

No

Sleeping less than normal amount by up to one hour

Sleeping less than normal amount by more than one hour

Need for sleep appears decreased; less than four hours

Denies need for sleep; has stayed up one night or more

Irritability - Has your child appeared irritable?

No more than usual

More grouchy or crabby

Irritable openly several times throughout the day; recent episodes of anger with family, at school, or with friends

Frequently irritable to point of being rude or withdrawn

Hostile and uncooperative about all the time

Speech (rate and amount) - Is your child talking more quickly or more than usual?

No change

Seems more talkative

Talking faster or more to say at times

Talking more or faster to point he/she is difficult to interrupt

Continuous speech; unable to interrupt

Thoughts - Has your child shown changes in his/her thought patterns?

No

Thinking faster; some decrease in concentration; talking “around the issue”

Distractible; loses track of the point; changes topics frequently; thoughts racing

Difficult to follow; goes from one idea to the next; topics do not relate; makes rhymes or repeats words

Not understandable; he/she doesn’t seem to make any sense

Content - Is your child talking about different things than usual?

No

He/she has new interests and is making more plans

Making special projects; more religious or interested in God

Thinks more of him/herself; believes he/she has special powers; believes he/she is receiving special messages

Is hearing unreal noises/voices; detects odors no one else smells; feels unusual sensations; has unreal beliefs

Disruptive-Aggressive Behavior - Has your child been more disruptive or aggressive?

No; he/she is cooperative

Sarcastic; loud; defensive

More demanding; making threats

Has threatened a family member or teacher; shouting; knocking over possessions/ furniture or hitting a wall

Has attacked family member, teacher, or peer; destroyed property; cannot be spoken to without violence

Appearance - Has your child’s interest in his/her appearance changed recently?

No

A little less or more interest in grooming than usual

Doesn’t care about washing or changing clothes, or is changing clothes more than three time a day

Very messy; needs to be supervised to finish dressing; applying makeup in overly- done or poor fashion

Refuses to dress appropriately; wearing bizarre styles

Insight - Does your child think he/she needs help at this time?

Yes; admits difficulties and wants treatment

Believes there might be something wrong

Admits to change in behavior but denies he/she needs help

Admits behavior might have changed but denies need for help

Denies there have been any changes in his/her behavior/thinking

Signature of Parent / Guardian: *

Clear