ADHD Child Follow Up Form

Caring for You and Your Whole Family

Please fill in the information for the visit before your appointment
Name

First NameLast Name
Date of Birth
Visit Date
How often does your child display these behaviors?

0= never

1= occasionally/infrequently

2= often/frequently

3= very often

Fails to pay attention to details or makes careless mistakes in their homework

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty sustaining attention in tasks or activities

	0	1	2	3

0 is Never, 3 is Very Often

Does not listen when spoken to directly

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty organizing tasks or activities

	0	1	2	3

0 is Never, 3 is Very Often

Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort

	0	1	2	3

0 is Never, 3 is Very Often

Loses things necessary for tasks or activities (schools assignments, pencils, or books)

	0	1	2	3

0 is Never, 3 is Very Often

Is easily distracted by extraneous stimuli

	0	1	2	3

0 is Never, 3 is Very Often

Is forgetful in daily activities

	0	1	2	3

0 is Never, 3 is Very Often

Doesn't follow through with instructions (i.e. chores)

	0	1	2	3

0 is Never, 3 is Very Often

Fidgets with hands or feet or squirms in seat

	0	1	2	3

0 is Never, 3 is Very Often

Leaves seat during meals

	0	1	2	3

0 is Never, 3 is Very Often

Runs around or climbs excessively in situations where remaining seated is expected

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty playing or engaging in leisure activities quietly

	0	1	2	3

0 is Never, 3 is Very Often

Is "on the go" or acts as if "driven by a motor"

	0	1	2	3

0 is Never, 3 is Very Often

Talks excessively

	0	1	2	3

0 is Never, 3 is Very Often

Blurts out answers before questions have been completed

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty waiting in line

	0	1	2	3

0 is Never, 3 is Very Often

Interrupts or intrudes on others (i.e. butts into conversations or games)

	0	1	2	3

0 is Never, 3 is Very Often

Should be Empty:

Caring for You and Your Whole Family