William Friedrich, Ph.D.
Please circle the number that tells how often your child has shown the following behaviors recently or in the last 6 months.
| 1. |
0 |
1 |
2 |
3 |
Stands too close to people |
| 2. |
0 |
1 |
2 |
3 |
Talks about wanting to be the opposite sex |
| 3. |
0 |
1 |
2 |
3 |
Touches private parts when in public places |
| 4. |
0 |
1 |
2 |
3 |
Masturbates with hand |
| 5. |
0 |
1 |
2 |
3 |
Draws sex parts when drawing pictures of people |
| 6. |
0 |
1 |
2 |
3 |
Touches or tries to touch mother's or other women's breasts |
| 7. |
0 |
1 |
2 |
3 |
Masturbates with object |
| 8. |
0 |
1 |
2 |
3 |
Touches other people's private parts |
| 9. |
0 |
1 |
2 |
3 |
Imitates the act of sexual intercourse |
| 10. |
0 |
1 |
2 |
3 |
Puts mouth on another child's or adult's sex parts |
| 11. |
0 |
1 |
2 |
3 |
Touches private parts when at home |
| 12. |
0 |
1 |
2 |
3 |
Uses words that describe sex acts |
| 13. |
0 |
1 |
2 |
3 |
Touches animals' sexual parts |
| 14. |
0 |
1 |
2 |
3 |
Makes sexual sounds (sighing, moaning, heavy breathing, etc.) |
| 15. |
0 |
1 |
2 |
3 |
Asks others to engage in sexual acts with her/him |
| 16. |
0 |
1 |
2 |
3 |
Rubs body against people or furniture |
| 17. |
0 |
1 |
2 |
3 |
Inserts or tries to insert objects in vagina or anus |
| 18. |
0 |
1 |
2 |
3 |
Tries to look at people when they are nude or undressing |
| 19. |
0 |
1 |
2 |
3 |
Imitates sexual behavior with dolls or stuffed animals |
| 20. |
0 |
1 |
2 |
3 |
Shows private parts to adults |
| 21. |
0 |
1 |
2 |
3 |
Tries to look at pictures of nude or partially dressed people (may include catalogs) |
| 22. |
0 |
1 |
2 |
3 |
Talks about sexual acts |
| 23. |
0 |
1 |
2 |
3 |
Kisses adults they do not know well |
| 24. |
0 |
1 |
2 |
3 |
Gets upset by public displays of affection |
| 25. |
0 |
1 |
2 |
3 |
Overly friendly with men they do not know well |
| 26. |
0 |
1 |
2 |
3 |
Kisses other children they do not know well |
| 27. |
0 |
1 |
2 |
3 |
Talks in a flirtatious manner |
| 28. |
0 |
1 |
2 |
3 |
Tries to undress other children or adults against their will (opening pants, shirt,
etc.) |
| 29. |
0 |
1 |
2 |
3 |
Asks to look at nude or sexually explicit TV shows (may include videos or HBO-type
shows) |
| 30. |
0 |
1 |
2 |
3 |
When kissing, tries to put tongue in other person's mouth |
| 31. |
0 |
1 |
2 |
3 |
Hugs adults they do not know well |
| 32. |
0 |
1 |
2 |
3 |
Shows private parts to children |
| 33. |
0 |
1 |
2 |
3 |
If a girl, overly aggressive; if a boy, overly passive |
| 34. |
0 |
1 |
2 |
3 |
Seems very interested in opposite sex |
| 35. |
0 |
1 |
2 |
3 |
Tries to put mouth on mother's or other women's breasts |
| 36. |
0 |
1 |
2 |
3 |
Other sexual behaviors (please describe) |
