1.

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* Child's First Name

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* Child's Last name

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* After learning of a family member's life-threatening illness, it is common for people to experience some changes in feelings and behavior. This is a normal part of coping with the impact of the illness. The following list includes several areas in which children may display problems, whether or not a family member has a life-threatening illness. We are interested in each child's functioning in each area NOW, since coming to TLC. Please use the following scale to rate the extent to which these statements apply to your child.

  1 - Does not apply 2 3 - Sometimes 4 5 - Most of the time
My child is moody, irritable or easily upset.
My child has nightmares or bad dreams.
My child does not sleep well, or sleeps too much.
My child gets angry or has tantrums.
My child has trouble paying attention.
My child has difficulty with schoolwork.
My child has aches and pains.
My child is frequently sick.
My child is anxious and worried.
My child does not want to be apart from me.
My child is quiet and withdrawn.
My child is overly active or impulsive.
It's hard for my child to express his/her feelings.
My child gets into trouble.
My child has talked about wanting to die.

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* What was the relationship of the person who has a life-threatening illness to this child?

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* What is the name of the illness?

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