Parents' Rating Scale

Life Change Associates

2520 S. 5th Avenue Pocatello, ID 83204

Telephone: 208-233-5433
Fax: 877-284-2783

Patient's Name

To be filled out by the mother of the subject (or father only if mother is unavailable).

Today's Date

Listed below are items concerning children's behavior and the problems they sometimes have. Read each item carefully and decide how much you think your child was bothered by these problems when he/she was between six and ten years old. Rate the amount of the problem by putting a check in the column that describes your child at that time.

Restless (overactive)

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Excitable, impulsive

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Disturbs other children

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Fails to finish things started (short attention span)

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Fidgeting

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Inattentive, distractible

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Demands must be met immediately; gets frustrated

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Cries

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

Mood changes quickly

0 = Not at all

1 = Just a litte

2 = Pretty much

3 = Very much

Temper outbursts (explosive and unpredictable behavior)

0 = Not at all

1 = Just a little

2 = Pretty much

3 = Very much

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