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© M. Kutscher 2002, 2006. May copy for patient use.
Subject (if teacher):
Please rate the severity of each problem listed.
add comments below!
(0)none (1)slight (2)moderate
Trouble attending to work that child understands well_____
Trouble attending to work that child understands poorly___
Requires one-to-one attention to get work done _____
Impulsive (trouble waiting turn, blurts out answers)_____
Hyperactive (fidgity, trouble staying seated) _____
Homework not handed in _____
Inconsistent work and effort _____
Poor sense of time _____
Does not seem to talk through problems _____
Easily overwhelmed _____
Blows up easily _____
Trouble switching activities _____
Hyper-focused at times _____
Poor handwriting _____
Certain academic tasks seem difficult (specifiy) _____
Seems deliberately spiteful, cruel or annoying _____
Anxious, edgy, stressed or painfully worried _____
Obsessive thoughts or fears; perseverative rituals_____
Irritated for hours or days on end (not just frequent, brief blow-ups)_____
Depressed, sad, or unhappy _____
Extensive mood swings _____
Tics: repetitive movements or noises _____
Poor eye contact _____
Does not catch on to social cues _____
Limited range of interests and interactions _____
Unusual sensitivity to sounds, touch, textures, movement or taste_____
Coordination difficulties _____
Other (specify) _____
If the child is on medication, please answer the following questions:
Can you tell when the child is on medication or not?
Does the medication work consistently throughout the day?
Does the child appear to be on too much or too little medication?
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