ADHD - Parent

Child’s Name:

Date of Birth:

Person Completing Form:

Directions

Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months or since their last medication appointment.

Is this evaluation based on a time when the child

was on medication was not on medication not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes, for example with homework

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

2. Has difficulty keeping attention to what needs to be done

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

3. Does not seem to listen when spoken to directly

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

5. Has difficulty organizing tasks and activities

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

7. Loses things necessary for tasks or activities (toys, assignments, pencils or books)

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

8. Is easily distracted by noises or other stimuli

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

9. Is forgetful in daily activities

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

10. Fidgets with hands or feet or squirms in seat.

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

11. Leaves seat when remaining seated is expected

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

12. Runs about or climbs too much when remaining seated is expected

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

13. Has difficulty playing or beginning quiet play activities

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

14. Is “on the go” or often acts as if “driven by a motor”

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

15. Talks too much

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

16. Blurts out answers before questions have been completed

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

17. Has difficulty waiting his or her turn

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

18. Interrupts or intrudes in on others’ conversations and/or activities

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

19. Argues with adults

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

20. Loses temper

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

21. Actively defies or refuses to go along with adults’ requests or rules

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

22. Deliberately annoys people

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

23. Blames others for his or her mistakes or misbehaviors

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

24. Is touchy or easily annoyed by others

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

25. Is angry or resentful

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

26. Is spiteful and wants to get even

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

27. Bullies, threatens, or intimidates others

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

28. Starts physical fights

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

30. Is truant from school (skips school) without permission

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

31. Is physically cruel to people

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

32. Has stolen things that have value

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

33. Deliberately destroys others’ property

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

35. Is physically cruel to animals

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

36. Has deliberately set fires to cause damage

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

37. Has broken into someone else’s home, business, or car

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

38. Has stayed out at night without permission.

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

39. Has run away from home overnight

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

40. Has forced someone into sexual activity

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

41. Is fearful, anxious, or worried

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

42. Is afraid to try new things for fear of making mistakes

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

43. Feels worthless or inferior

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

44. Blames self for problems, feels guilty

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

46. Is sad, unhappy, or depressed

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

47. Is self-conscious or easily embarrassed

0 = Never 1 = Occasionally 2 = Often 3 = Very Often

Performance

48. Overall school performance

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

49. Reading

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

50. Writing

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

51. Mathematics

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

52. Relationship with parents

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

53. Relationship with siblings

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

54. Relationship with peers

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

Participation in organized activities (eg, teams)

1 = Excellent 2 = Above Average 3 = Average 4 = Somewhat of a problem 5 = Problematic

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