| Name | Age | ||
|---|---|---|---|
| Grade | Date |
For each symptom, mark if it is observed regularly at home or school.
| Symptom | Observed |
|---|---|
| Has difficulty sustaining attention in tasks or play | |
| Often does not seem to listen when spoken to directly | |
| Fails to give close attention to details, makes careless mistakes | |
| Does not follow through on instructions; fails to finish tasks | |
| Has trouble organizing tasks and activities | |
| Avoids or dislikes tasks that require sustained mental effort | |
| Loses things necessary for tasks or activities | |
| Easily distracted by extraneous stimuli | |
| Forgetful in daily activities |
| Symptom | Observed |
|---|---|
| Fidgets with hands/feet or squirms in seat | |
| Leaves seat when remaining seated is expected | |
| Runs or climbs in inappropriate situations | |
| Unable to play quietly | |
| Often "on the go" or acts as if "driven by a motor" | |
| Talks excessively | |
| Blurts out answers before questions have been completed | |
| Has trouble waiting turn | |
| Interrupts or intrudes on others |