DSHS Form 10-509 "Pediatric Symptoms Checklist (Psc-17)" - Washington (Arabic)

Form DSHS10-509 AR is a Washington State Department of Social and Health Services form also known as the "Pediatric Symptoms Checklist (psc-17)". The latest edition of the form was released in August 1, 2014 and is available for digital filing.

Download an up-to-date Form DSHS10-509 AR in PDF-format down below or look it up on the Washington State Department of Social and Health Services Forms website.

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Download DSHS Form 10-509 "Pediatric Symptoms Checklist (Psc-17)" - Washington (Arabic)

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‫ﺍﻟﺗﺎﺭﻳﺦ‬
‫ﻗﺎﺋﻣﺔ ﻣﺭﺍﺟﻌﺔ ﺃﻋﺭﺍﺽ ﺍﻷﻁﻔﺎﻝ‬
(
PSC–17
)
Pediatric Symptom Checklist (PSC–17)
‫ﺗﺎﺭﻳﺦ ﻣﻳﻼﺩ ﺍﻟﻁﻔﻝ‬
‫ﺍﺳﻡ ﺍﻟﻁﻔﻝ‬
‫ﺍﺳﻡ ﺍﻟﺷﺧﺹ ﺍﻟﺫﻱ ﺃﻛﻣﻝ ﻫﺫﺍ ﺍﻟﻧﻣﻭﺫﺝ‬
‫ﺍﻻﺳﻡ ﺍﻷﺧﻳﺭ‬
‫ﺍﻻﺳﻡ ﺍﻷﻭﻝ‬
‫ﺍﻻﺳﻡ ﺍﻷﺧﻳﺭ‬
‫ﺍﻻﺳﻡ ﺍﻷﻭﻝ‬
‫ﻙ‬
‫ﻳﺭﺟﻰ ﺗﺣﺩﻳﺩ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻭﺟﻭﺩ ﺗﺣﺕ ﺍﻟﻌﻧﻭﺍﻥ ﺍﻟﺫﻱ ﻳﺻﻑ ﻁﻔﻠﻙ ﺃﻭ ﻳﺻﻔ‬
For Office Use
.‫ﺃﻧﺕ ﺑﺷﻛﻝ ﺃﻓﺿﻝ‬
Only
‫ﻟﻼﺳﺗﺧﺩﺍﻡ ﻓﻲ ﺍﻟﻣﻛﺗﺏ‬
)
‫( ﻓﻲ ﺑﻌﺽ‬
) 1
‫( ﻏﺎﻟ ﺑ ً ﺎ‬
) 2
‫( ﺃﺑ ﺩ ًﺍ‬
) 0
(
‫ﻓﻘﻁ‬
‫ﺍﻷﺣﻳﺎﻥ‬
‫ﻳﺷﻌﺭ ﺑﺎﻟﺣﺯﻥ، ﻏﻳﺭ ﺳﻌﻳﺩ‬
1 .
‫ﻳﺷﻌﺭ ﺑﺎﻟﺳﻌﺎﺩﺓ‬
2 .
‫ﻣﻧﻁﻭﻱ ﻋﻠﻰ ﻧﻔﺳﻪ‬
3 .
Internalizing
‫ﻳﻘﻠﻖ ﻛﺛﻳﺭ ً ﺍ‬
4 .
Total
‫ﻳﺷﻌﺭ ﺑﺎﻣﺗﻼﻛﻪ ﻟﻘﻠﻳﻝ ﻣﻥ ﺍﻟﻣﺭﺡ‬
5 .
‫ﺿﻳﻖ ﺍﻟﺻﺩﺭ، ﻏﻳﺭ ﻗﺎﺩﺭ ﻋﻠﻰ ﺍﻟﺟﻠﻭﺱ ﺳﺎﻛ ﻧ ً ﺎ‬
6 .
‫ﺟﺩﺍ‬
‫ﺃﺣﻼﻡ ﺍﻟﻳﻘﻅﺔ ﻛﺛﻳﺭﺓ‬
7 .
‫ﺑﺳﻬﻭﻟﺔ‬
‫ﺷﺎﺭﺩ ﺍﻟﺫﻫﻥ‬
8 .
Attention
‫ﻟﺩﻳﻪ ﺻﻌﻭﺑﺔ ﻓﻲ ﺍﻟﺗﺭﻛﻳﺯ‬
9 .
Total
‫ﻳﺗﺻﺭﻑ ﻛﻣﺎ ﻟﻭ ﻛﺎﻥ ﻳﻘﻭﺩﻩ ﻣﺣﺭﻙ‬
.
10
‫ﻳﺗﻌﺎﺭﻙ ﻣﻊ ﺍﻷﻁﻔﺎﻝ ﺍﻵﺧﺭﻳﻥ‬
.
11
‫ﺍﻟﻘﻭﺍﻋﺩ‬
‫ﻻ ﻳﺳﺗﻣﻊ ﺇﻟﻰ‬
.
12
‫ﻣﺷﺎﻋﺭ ﺍﻵﺧﺭﻳﻥ‬
‫ﻻ ﻳﻔﻬﻡ‬
.
13
‫ﻳﺿﺎﻳﻖ ﺍﻵﺧﺭﻳﻥ‬
.
14
‫ﻳﻠﻭﻡ / ﺗﻠﻭﻡ ﺍﻵﺧﺭﻳﻥ ﺑﺳﺑﺏ ﻣﺷﺎﻛﻠﻪ / ﻣﺷﺎﻛﻠﻬﺎ‬
.
15
Externalizing
‫ﻳﺭﻓﺽ ﺍﻟﻣﺷﺎﺭﻛﺔ‬
.
16
Total
‫ﻳﺄﺧﺫ / ﺗﺄﺧﺫ ﺍﻷﺷﻳﺎء ﺍﻟﺗﻲ ﻻ ﺗﺧﺻﻪ / ﺗﺧﺻﻬﺎ‬
.
17
‫ﺍﻟﺩﺭﺟﺔ ﺍﻟﻛﻠﻳﺔ‬
.‫ﺩﺭﺟﺔ ﺃﻭ ﺃﻛﺛﺭ ﻗﺩ ﻳﺷﻳﺭ ﺇﻟﻰ ﺍﻟﺣﺎﺟﺔ ﺇﻟﻰ ﺗﻘﻳﻳﻡ ﻣﻥ ﻗﺑﻝ ﺃﺣﺩ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺍﻟﻁﺑﻳﻳﻥ ﺍﻟﻣﺅﻫﻠﻳﻥ ﺃﻭ ﺃﺣﺩ ﻣﻬﻧﻳﻲ ﺍﻟﺻﺣﺔ ﺍﻟﻌﻘﻠﻳﺔ‬
15
‫ﺇﻥ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ‬
PSC-17
DSHS 10-509 AR (08/2014) Arabic
‫ﺍﻟﺗﺎﺭﻳﺦ‬
‫ﻗﺎﺋﻣﺔ ﻣﺭﺍﺟﻌﺔ ﺃﻋﺭﺍﺽ ﺍﻷﻁﻔﺎﻝ‬
(
PSC–17
)
Pediatric Symptom Checklist (PSC–17)
‫ﺗﺎﺭﻳﺦ ﻣﻳﻼﺩ ﺍﻟﻁﻔﻝ‬
‫ﺍﺳﻡ ﺍﻟﻁﻔﻝ‬
‫ﺍﺳﻡ ﺍﻟﺷﺧﺹ ﺍﻟﺫﻱ ﺃﻛﻣﻝ ﻫﺫﺍ ﺍﻟﻧﻣﻭﺫﺝ‬
‫ﺍﻻﺳﻡ ﺍﻷﺧﻳﺭ‬
‫ﺍﻻﺳﻡ ﺍﻷﻭﻝ‬
‫ﺍﻻﺳﻡ ﺍﻷﺧﻳﺭ‬
‫ﺍﻻﺳﻡ ﺍﻷﻭﻝ‬
‫ﻙ‬
‫ﻳﺭﺟﻰ ﺗﺣﺩﻳﺩ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻭﺟﻭﺩ ﺗﺣﺕ ﺍﻟﻌﻧﻭﺍﻥ ﺍﻟﺫﻱ ﻳﺻﻑ ﻁﻔﻠﻙ ﺃﻭ ﻳﺻﻔ‬
For Office Use
.‫ﺃﻧﺕ ﺑﺷﻛﻝ ﺃﻓﺿﻝ‬
Only
‫ﻟﻼﺳﺗﺧﺩﺍﻡ ﻓﻲ ﺍﻟﻣﻛﺗﺏ‬
)
‫( ﻓﻲ ﺑﻌﺽ‬
) 1
‫( ﻏﺎﻟ ﺑ ً ﺎ‬
) 2
‫( ﺃﺑ ﺩ ًﺍ‬
) 0
(
‫ﻓﻘﻁ‬
‫ﺍﻷﺣﻳﺎﻥ‬
‫ﻳﺷﻌﺭ ﺑﺎﻟﺣﺯﻥ، ﻏﻳﺭ ﺳﻌﻳﺩ‬
1 .
‫ﻳﺷﻌﺭ ﺑﺎﻟﺳﻌﺎﺩﺓ‬
2 .
‫ﻣﻧﻁﻭﻱ ﻋﻠﻰ ﻧﻔﺳﻪ‬
3 .
Internalizing
‫ﻳﻘﻠﻖ ﻛﺛﻳﺭ ً ﺍ‬
4 .
Total
‫ﻳﺷﻌﺭ ﺑﺎﻣﺗﻼﻛﻪ ﻟﻘﻠﻳﻝ ﻣﻥ ﺍﻟﻣﺭﺡ‬
5 .
‫ﺿﻳﻖ ﺍﻟﺻﺩﺭ، ﻏﻳﺭ ﻗﺎﺩﺭ ﻋﻠﻰ ﺍﻟﺟﻠﻭﺱ ﺳﺎﻛ ﻧ ً ﺎ‬
6 .
‫ﺟﺩﺍ‬
‫ﺃﺣﻼﻡ ﺍﻟﻳﻘﻅﺔ ﻛﺛﻳﺭﺓ‬
7 .
‫ﺑﺳﻬﻭﻟﺔ‬
‫ﺷﺎﺭﺩ ﺍﻟﺫﻫﻥ‬
8 .
Attention
‫ﻟﺩﻳﻪ ﺻﻌﻭﺑﺔ ﻓﻲ ﺍﻟﺗﺭﻛﻳﺯ‬
9 .
Total
‫ﻳﺗﺻﺭﻑ ﻛﻣﺎ ﻟﻭ ﻛﺎﻥ ﻳﻘﻭﺩﻩ ﻣﺣﺭﻙ‬
.
10
‫ﻳﺗﻌﺎﺭﻙ ﻣﻊ ﺍﻷﻁﻔﺎﻝ ﺍﻵﺧﺭﻳﻥ‬
.
11
‫ﺍﻟﻘﻭﺍﻋﺩ‬
‫ﻻ ﻳﺳﺗﻣﻊ ﺇﻟﻰ‬
.
12
‫ﻣﺷﺎﻋﺭ ﺍﻵﺧﺭﻳﻥ‬
‫ﻻ ﻳﻔﻬﻡ‬
.
13
‫ﻳﺿﺎﻳﻖ ﺍﻵﺧﺭﻳﻥ‬
.
14
‫ﻳﻠﻭﻡ / ﺗﻠﻭﻡ ﺍﻵﺧﺭﻳﻥ ﺑﺳﺑﺏ ﻣﺷﺎﻛﻠﻪ / ﻣﺷﺎﻛﻠﻬﺎ‬
.
15
Externalizing
‫ﻳﺭﻓﺽ ﺍﻟﻣﺷﺎﺭﻛﺔ‬
.
16
Total
‫ﻳﺄﺧﺫ / ﺗﺄﺧﺫ ﺍﻷﺷﻳﺎء ﺍﻟﺗﻲ ﻻ ﺗﺧﺻﻪ / ﺗﺧﺻﻬﺎ‬
.
17
‫ﺍﻟﺩﺭﺟﺔ ﺍﻟﻛﻠﻳﺔ‬
.‫ﺩﺭﺟﺔ ﺃﻭ ﺃﻛﺛﺭ ﻗﺩ ﻳﺷﻳﺭ ﺇﻟﻰ ﺍﻟﺣﺎﺟﺔ ﺇﻟﻰ ﺗﻘﻳﻳﻡ ﻣﻥ ﻗﺑﻝ ﺃﺣﺩ ﺍﻟﻣﻭﻅﻔﻳﻥ ﺍﻟﻁﺑﻳﻳﻥ ﺍﻟﻣﺅﻫﻠﻳﻥ ﺃﻭ ﺃﺣﺩ ﻣﻬﻧﻳﻲ ﺍﻟﺻﺣﺔ ﺍﻟﻌﻘﻠﻳﺔ‬
15
‫ﺇﻥ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ‬
PSC-17
DSHS 10-509 AR (08/2014) Arabic