Today’s Date_________________
Child’s Name:__________________________________
Date of Birth: ______________
Parent’s Name:_________________________________

Each rating should be considered in the context of what is appropriate for the age of your child.

Is this evaluation based on a time when the child was: (please circle one)
On medication Not on medication Not sure

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.

Symptoms:
1. Does not pay attention to details or makes careless mistakes with, for example, homework
0 1 2 3

2. Has difficulty keeping attention to what needs to be done
0 1 2 3

3. Does not seem to listen when spoken to directly
0 1 2 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
0 1 2 3

5. Has difficulty organizing tasks and activities
0 1 2 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
0 1 2 3

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
0 1 2 3

8. Is easily distracted by noises or other 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 when remaining seated is expected
0 1 2 3

12. Runs about or climbs too much when remaining seated is expected
0 1 2 3

13. Has difficulty playing or beginning quiet play activities
0 1 2 3

14. Is “on the go” or often acts as if “driven by a motor”
0 1 2 3

15. Talks too much
0 1 2 3

16. Blurts out answers before questions have been completed
0 1 2 3

17. Has difficulty waiting his or her turn

0 1 2 3

18. Interrupts or intrudes in on others’ conversations and/or activities
0 1 2 3

Performance

Excellent Above Average Average Problem Problematic
19. Overall school performance 1 2 3 4 5

20. Reading 1 2 3 4 5

21. Writing 1 2 3 4 5

22. Mathematics 1 2 3 4 5

23. Relationship with parents 1 2 3 4 5

24. Relationship with siblings 1 2 3 4 5

25. Relationship with peers 1 2 3 4 5

26. Participates in organized activities
(eg, teams) 1 2 3 4 5

Side Effects:
Has your child experienced any of the following side effects or problems in the past week?
Are these side effects currently a problem?

Use the following to assess severity
None: The symptom is not present.

Mild: The symptom is present but not significant enough to cause concern to your child, you, or to his/her friends/peers. The presence of the symptom at this level would NOT be a reason to stop medication.

Moderate: The symptom causes impairment of functioning or social embarrassment to such a degree that the negative impact on social and school performance should be weighed carefully to justify benefit of continuing medication must be considered.

Severe: The symptom causes impairment of functioning or social embarrassment to such a degree that the child should not continue to receive this medication or dose of medication as part of current treatment.

Repetitive movements, tics, jerking, twitching, eye blinking—explain below
None Mild Moderate Severe

Buccal-lingual movements – tongue thrust, jaw clenching, lip/cheek biting
None Mild Moderate Severe

Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
None Mild Moderate Severe

Worried/anxious
None Mild Moderate Severe

Dull, Tired, Listless
None Mild Moderate Severe

Headache
None Mild Moderate Severe

Stomachache
None Mild Moderate Severe

Crabby, Irritable
None Mild Moderate Severe

Tearful, sad, depressed
None Mild Moderate Severe

Socially withdrawn—decreased interaction with others
None Mild Moderate Severe

Hallucinations – seeing things that aren’t there
None Mild Moderate Severe

Loss of appetite
None Mild Moderate Severe

Trouble sleeping (time went to sleep)
None Mild Moderate Severe

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