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 | ||||
| 35. Learning difficulties as reflected by the grades |
Be sure to PRINT out the completed questionnaire before leaving this page.