Directions: Each rating should be considered in the context of what is appropriate for the age of your child youn are rating and should reflect that child's behavior since the beginning of the school year.Please indicate the number of weeks or months you have been able to evaluate the behaviors.
Symptoms
Fails to give attention to details or makes careless mistakes in schoolwork: - Never Occasionally Often Very Often
Has difficulty sustaining attention to tasks or activities: - Never Occasionally Often Very Often
Does not seem to listen when spoken to directly: - Never Occasionally Often Very Often
Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand): - Never Occasionally Often Very Often
Has difficulty organizing tasks and activities: - Never Occasionally Often Very Often
Avoids, dislikes, or is reluctant to engage in tasks that require sustained: - Never Occasionally Often Very Often
Loses things necessary for tasks or activities (toys, assignments, pencils, or books): - Never Occasionally Often Very Often
Is easily distracted by noises or other stimuli: - Never Occasionally Often Very Often
Is forgetful in daily activities: - Never Occasionally Often Very Often
Fidgets with hands or feet or squirms in seat: - Never Occasionally Often Very Often
Leaves seat in classroom or in other situations when remaining seated is expected: - Never Occasionally Often Very Often
Runs about or climbs excessively in situations when remaining seated is expected: - Never Occasionally Often Very Often
Has difficulty playing or engaging in leisure activities quietly: - Never Occasionally Often Very Often
Is “on the go” or often acts as if “driven by a motor”: - Never Occasionally Often Very Often
Talks excessively: - Never Occasionally Often Very Often
Blurts out answers before questions have been completed: - Never Occasionally Often Very Often
Has difficulty waiting in line: - Never Occasionally Often Very Often
Interrupts or intrudes in on others (eg, butts into conversations/games): - Never Occasionally Often Very Often
Loses temper: - Never Occasionally Often Very Often
Actively defies or refuses to comply with adult’s requests or rules: - Never Occasionally Often Very Often
Is angry or resentful: - Never Occasionally Often Very Often
Is spiteful and vindictive: - Never Occasionally Often Very Often
Bullies, threatens, or intimidates others: - Never Occasionally Often Very Often
Initiates physical fights: - Never Occasionally Often Very Often
Lies to to obtain goods for favors or to avoid obligations (ie,“cons” others): - Never Occasionally Often Very Often
Is physically cruel to people: - Never Occasionally Often Very Often
Has stolen items of nontrivial value: - Never Occasionally Often Very Often
Deliberately destroys others’ property: - Never Occasionally Often Very Often
Is fearful, anxious, or worried: - Never Occasionally Often Very Often
Is self-conscious or easily embarrassed: - Never Occasionally Often Very Often
Is afraid to try new things for fear of making mistakes: - Never Occasionally Often Very Often
Feels worthless or inferior: - Never Occasionally Often Very Often
Blames self for problems, feels guilty: - Never Occasionally Often Very Often
Feels lonely, unwanted, or unloved; complains that “no one loves him or her”: - Never Occasionally Often Very Often
Is sad, unhappy, or depressed: - Never Occasionally Often Very Often
Performance
Academic Performance
Reading: - Excellent Above Average Average Somewhat of a Problem Problematic
Writing expressions: - Excellent Above Average Average Somewhat of a Problem Problematic
Mathematics: - Excellent Above Average Average Somewhat of a Problem Problematic
Classroom Behavioral Performace
Relationship with peers: - Excellent Above Average Average Somewhat of a Problem Problematic
Following directions: - Excellent Above Average Average Somewhat of a Problem Problematic
Disrupting class: - Excellent Above Average Average Somewhat of a Problem Problematic
Assignment completion: - Excellent Above Average Average Somewhat of a Problem Problematic
Organizational skills: - Excellent Above Average Average Somewhat of a Problem Problematic
