| Name | Date | ||
|---|---|---|---|
| Age | Gender |
| # | Item | Yes | No |
|---|---|---|---|
| 1 | Recent changes in mood or behavior | ||
| 2 | Decline in academic performance | ||
| 3 | Loss of interest in previously enjoyed activities | ||
| 4 | Unexplained need for money or stealing | ||
| 5 | Change in friends or peer group | ||
| 6 | Physical signs (red eyes, nosebleeds, etc.) | ||
| 7 | Sudden weight loss or gain | ||
| 8 | Rebellious or secretive behavior | ||
| 9 | Evidence of drug paraphernalia | ||
| 10 | Frequent absences from school or home |