Please answer all questions below about your child; then print the completed page to bring to 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. Eating difficulties | ||||
| 21. Sleeping difficulties | ||||
| 22. Headaches | ||||
| 23. Bed wetting | ||||
| 24. Speech delay (current or history of speech delay) | ||||
| 25. Abdominal pain or diarrhea | ||||
| 26. Anxiety (excessive fear) afraid of new situations | ||||
| 27. Depressed mood (unhappy child, cries easily, irritable) | ||||
| 28. Compulsive behavior (rituals, arranging objects, etc.) | ||||
| 29. Oppositional and defiant (refuses to cooperate, answers back, disobedient) | ||||
| 30. Cruel | ||||
| 31. Social difficulties (mocked by other kids), likes to be on his own | ||||
| 32. Very “difficult” child | ||||
| 33. Mood swings | ||||
| 34. Feels easily hurt or cheated | ||||
| 35. Risk taking behaviors, hitting, throwing, runs to street, plays with fire | ||||
| 36. Tics, eye blinking, facial twitches | ||||
| 37. Spacing out, blank stare, in his own world | ||||
| 38. Destroys toys or property | ||||
| 39. Lies frequently | ||||
| 40. Picks on things (nails, clothing) | ||||
| 41. Wants to run things |
Be sure to PRINT out the completed version before closing this page.