ADHD Assessment 12 years and under

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

Does not pay attention to details or makes careless mistakes with, for example, homework.

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty keeping attention to what needs to be done.

	0	1	2	3

0 is Never, 3 is Very Often

Does not seem to listen when spoken to directly.

	0	1	2	3

0 is Never, 3 is Very Often

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

	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 does not want to start tasks that require ongoing mental effort.

	0	1	2	3

0 is Never, 3 is Very Often

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

	0	1	2	3

0 is Never, 3 is Very Often

Is easily distracted by noises or other 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

Fidgets with hands or feet or squirms in seat.

	0	1	2	3

0 is Never, 3 is Very Often

Leaves seat when remaining seated is expected.

	0	1	2	3

0 is Never, 3 is Very Often

Runs about or climbs too much when remaining seated is expected.

	0	1	2	3

0 is Never, 3 is Very Often

Has difficulty playing or beginning quiet play activities.

	0	1	2	3

0 is Never, 3 is Very Often

Is “on the go” or often acts as if “driven by a motor.”

	0	1	2	3

0 is Never, 3 is Very Often

Talks too much.

	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 their turn.

	0	1	2	3

0 is Never, 3 is Very Often

Interrupts or intrudes in on others’ conversations and/or activities.

	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