Symptoms Questionnaire for Teachers



Please answer all questions below about the student; then print the completed page for the child’s appointment.

Click on the Appropriate Rating: Never Mild Often Severe
1. Poor attention to details
2. Careless mistakes in academic or other activities
3. Short attention span to tasks or play activities
4. Seems not to listen when spoken to
5. Difficulties following through and finishing tasks
6. Poor organization skills, procrastinates, takes a long time to start work
7. Avoids tasks requiring attention (homework, reading)
8. Loses and forgets things (school assignments, pencils, books)
9. Easily distracted (by external stimuli)
10. Forgetful in daily activities
11. Fidgets hands or squirms in seat
12. Gets up from chair inappropriately (can’t stay seated for a long time)
13. Runs, climbs excessively, notably overactive
14. Difficulties playing quietly
15. Up and on the go (as if driven by a motor)
16. Talks excessively
17. Answers before question completed
18. Difficulties waiting turn
19. Interrupts or intrudes into conversation or activity
20. Excessive demand for teacher’s attention
21. Disrespectful behavior towards the teacher
22. Doesn’t get along with other children
23.Lacks leadership
24. Led by others
25. Picked on by other kids
26. Bullies other children
27. Fights with other children, displays violent behavior
28. Difficult child to have in class
29. Fails to complete homework and school assignments
30. Disturbs other children, interrupts the class
31. Childish, immature
32. Is the class clown
33. Easily frustrated in efforts
34. Takes too long to complete tasks

Be sure to PRINT out the completed questionnaire before leaving this page.