Child/Teen ADHD Questionnaire
Observations of a minor by parents, teachers, guardians
Patient Name
*
First Name
Last Name
Your Name
First Name
Last Name
Relationship to patient
Parent/Step-parent
Guardian
Teacher
Other
Email - please type carefully and avoid errors
*
example@example.com
Phone Number
*
Attention MD is a virtual practice. Michigan laws require video connections for virtual sessions. Phone or audio-only connections are not an option. GoogleMeet no longer an option due to unreliability.
*
Zoom--preferred
Apple FaceTime--strong signal required
Contact email or phone number for the video connection (if different from above)
Issues to discuss at this visit
*
Weight
*
Height
Please provide your latest measurement, if available.
Blood pressure
*
From previous doctor visit if no home monitor
Pulse
*
Seated and relaxed for 5 minutes
Progress since last visit
*
Marked improvement
Significant improvement
Mild improvement
About the same
Mildly worse
Significantly worse
Markedly worse
Level of anxiety symptoms 1-10
*
1
2
3
4
5
6
7
8
9
10
Very Low
Very high
1 is Very Low, 10 is Very high
Level of depression symptoms 1-10
*
1
2
3
4
5
6
7
8
9
10
Very Low
Very High
1 is Very Low, 10 is Very High
Section 1
Section 2
Section 3 -
Section 4 -
Total Symptom Score
Calculation
Section 1
1. Doesn't finish things
*
Not at all
Just a little
Pretty much
Very much
2. Doesn't pay attention
*
Not at all
Just a little
Pretty much
Very much
3. Doesn't seem to listen
*
Not at all
Just a little
Pretty much
Very much
4. Difficulty following instructions
*
Not at all
Just a little
Pretty much
Very much
5. Difficulty getting organized
*
Not at all
Just a little
Pretty much
Very much
6. Avoids doing things that require a lot of mental effort
*
Not at all
Just a little
Pretty much
Very much
7. Loses things
*
Not at all
Just a little
Pretty much
Very much
8. Easily distracted
*
Not at all
Just a little
Pretty much
Very much
9. Forgetful
*
Not at all
Just a little
Pretty much
Very much
Section 2
1. Too much energy
*
Not at all
Just a little
Pretty much
Very much
2. Fidgety, restless
*
Not at all
Just a little
Pretty much
Very much
3. Interrupts, blurts out, immature responses
*
Not at all
Just a little
Pretty much
Very much
4. Acts without thinking, neglects consequences
*
Not at all
Just a little
Pretty much
Very much
5. Difficulty calming down once upset
*
Not at all
Just a little
Pretty much
Very much
6. Impatient, unable to wait turn
*
Not at all
Just a little
Pretty much
Very much
7. On the go, acts as if "driven by a motor"
*
Not at all
Just a little
Pretty much
Very much
8. Defensive, argumentative
*
Not at all
Just a little
Pretty much
Very much
9. Over-reacts, gets too excited or emotionally intense
*
Not at all
Just a little
Pretty much
Very much
Section 3
1. Emotionally insecure, vulnerable
*
Not at all
Just a little
Pretty much
Very much
2. Appears depressed
*
Not at all
Just a little
Pretty much
Very much
3. Anxious, fearful, panicky
*
Not at all
Just a little
Pretty much
Very much
4. Worries about future events, inadequacy, failure
*
Not at all
Just a little
Pretty much
Very much
5. Over-reacts, gets too excited or emotionally intense
*
Not at all
Just a little
Pretty much
Very much
6. Meticulous, perfectionist
*
Not at all
Just a little
Pretty much
Very much
7. Pessimistic, sees worst side of situations
*
Not at all
Just a little
Pretty much
Very much
8. Quick to perceive social rejection
*
Not at all
Just a little
Pretty much
Very much
9. Low self-esteem
*
Not at all
Just a little
Pretty much
Very much
Section 4
1. Dissatisfied, unhappy with life
*
Not at all
Just a little
Pretty much
Very much
2. Trouble completing homework, chores, responsibilities
*
Not at all
Just a little
Pretty much
Very much
3. Symptoms interfere with friendships, social development
*
Not at all
Just a little
Pretty much
Very much
4. Sleep problems--insomnia, daytime tiredness, irregular sleep
*
Not at all
Just a little
Pretty much
Very much
5. Symptoms interfere with learning
*
Not at all
Just a little
Pretty much
Very much
6. Symptoms interfere with family function
*
Not at all
Just a little
Pretty much
Very much
Symptom Total to enter
Submit
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