| Child's
Name:
Age:
DOB:
|
| Date:
Completed by:
|
| School: |
|
| Current Medication
Doses: |
|
|
|
Grade
|
| |
Not
at all |
Just a little |
Pretty much |
Very much |
| 1 . Fails to
give attention to details or makes careless
mistakes in school work |
0 |
1 |
2 |
3 |
| 2. Has difficulty
sustaining attention to tasks or activities |
0 |
1 |
2 |
3 |
| 3. Does not
seem to listen when spoken to directly |
0 |
1 |
2 |
3 |
| 4. Does not
follow through on instructions and fails
to finish school work (not due to oppositional
behavior or failure to understand) |
0 |
1 |
2 |
3 |
| 5. Has difficulty
organizing tasks and activities |
0 |
1 |
2 |
3 |
| 6. Avoids,
dislikes, or is reluctant to engage in
tasks that require sustained mental effort |
0 |
1 |
2 |
3 |
| 7. Loses things
necessary for tasks or activities (school
assignments, pencils, or books) |
0 |
1 |
2 |
3 |
| 8. Is easily
distracted by extraneous stimuli |
0 |
1 |
2 |
3 |
| 9. Is forgetful
in daily activities |
0 |
1 |
2 |
3 |
| 10. Fidgets
with hands or feet or squirms in seat |
0 |
1 |
2 |
3 |
| 11. Leaves
seat in classroom or in other situations
in which remaining seated is expected |
0 |
1 |
2 |
3 |
| 12. Runs about
or climbs excessively in situations in
which remaining seated is expected |
0 |
1 |
2 |
3 |
| 13. Has difficulty
playing or engaged in leisure activities
quietly |
0 |
1 |
2 |
3 |
| 14. Is "on
the go" or often acts as if "driven
by a motor" |
0 |
1 |
2 |
3 |
| 15. Talks excessively |
0 |
1 |
2 |
3 |
| 16. Blurts
out answers before questions have been
completed |
0 |
1 |
2 |
3 |
| 17. Has difficulty
waiting turns |
0 |
1 |
2 |
3 |
| 18. Interrupts
or intrudes on others (eg., butts into
conversations or games) |
0 |
1 |
2 |
3 |
| 19. Argues
with adults |
0 |
1 |
2 |
3 |
| 20. Loses temper |
0 |
1 |
2 |
3 |
| 21. Actively
defies or refuses to comply with adults'
requests or rules |
0 |
1 |
2 |
3 |
| 22. Deliberately
annoys people |
0 |
1 |
2 |
3 |
| 23. Blames
others for his or her mistakes or misbehaviors |
0 |
1 |
2 |
3 |
| 24. Is touchy
or easily annoyed by others |
0 |
1 |
2 |
3 |
| 25. Is angry
and resentful |
0 |
1 |
2 |
3 |
| 26. Is spiteful
and vindictive |
0 |
1 |
2 |
3 |
| 27. Bullies,
threatens, or intimidates others |
0 |
1 |
2 |
3 |
| 28. Initiates
physical fights |
0 |
1 |
2 |
3 |
| 29. Lies to
obtain goods for favors or to avoid obligations
(ie., “cons” others) |
0 |
1 |
2 |
3 |
| 30. Is truant
from school |
0 |
1 |
2 |
3 |
| 31. Is physically
cruel to people |
0 |
1 |
2 |
3 |
| 32. Has stolen
items of non-trivial value |
0 |
1 |
2 |
3 |
| 33. Deliberately
destroys otheis’ property |
0 |
1 |
2 |
3 |
| 34. Is fearful,
anxious, or worried |
0 |
1 |
2 |
3 |
| 35. Is self-conscious
or easily embarrassed |
0 |
1 |
2 |
3 |
| 36. Is afraid
to try new things for fear of making mistakes |
0 |
1 |
2 |
3 |
| 37. Feels worthless
or inferior |
0 |
1 |
2 |
3 |
| 38. Blames
self for problems, feels guilty |
0 |
1 |
2 |
3 |
| 39. Feels lonely,
unwanted, or unloved: complains that no
ones loves him/her |
0 |
1 |
2 |
3 |
| 40. Is sad,
unhappy, or depressed |
0 |
1 |
2 |
3 |
| POSSIBLE
SIDE EFFECTS FOR CURRENT MEDICATIONS:
|
| Appetite loss |
0 |
1 |
2 |
3 |
| Anxiety/nervousness |
0 |
1 |
2 |
3 |
| Headaches |
0 |
1 |
2 |
3 |
| Tics |
0 |
1 |
2 |
3 |
| Sleepiness |
0 |
1 |
2 |
3 |
| Stomach upset |
0 |
1 |
2 |
3 |
| Flat/withdrawn |
0 |
1 |
2 |
3 |
| Sad |
0 |
1 |
2 |
3 |
