Attention deficit monitoring form

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Attention Deficit / Hyperactivity Disorder (ADHD) Monitoring Form

Attention Deficit / Hyperactivity Disorder (ADHD) Monitoring Form

To monitor your child's attention deficit, assess each of the following items on a weekly basis and compile the total score. Low scores show a better control of the problem, but there is no specific target score.
Name:		Profile:


	Symptoms	Never	Occasionally	Often	Very often

1.	Does not pay attention or makes careless mistakes	0	1	2	3

2.	Has difficulty keeping attention to what needs to be done	0	1	2	3

3.	Does not seem to listen when spoken to directly	0	1	2	3

4.	Does not follow through when given directions and fails to finish activities	0	1	2	3

5.	Has difficulty organizing tasks and activities	0	1	2	3

6.	Avoids or does not want to start tasks that require ongoing mental effort	0	1	2	3

7.	Loses things necessary for tasks or activities (toys, pencils or books)	0	1	2	3

8.	Is easily distracted by noises or other stimuli	0	1	2	3

9.	Is forgetful in daily activities	0	1	2	3

10.	Fidgets with hands or feet or squirms in seat	0	1	2	3

11.	Leaves seat when remaining seated is expected	0	1	2	3

12.	Runs about or climbs too much when remaining seated is expected	0	1	2	3

13.	Has difficulty playing or beginning quiet play activities	0	1	2	3

14.	Is "on the go" or often acts as if "driven by a motor"	0	1	2	3

15.	Talks too much	0	1	2	3

16.	Blurts out answers before questions have been completed	0	1	2	3

17.	Has difficulty waiting his or her turn	0	1	2	3

18.	Interrupts or intrudes on others' conversations and/or activities	0	1	2	3



	Behaviour / performance	Excellent	Above average	Average	Problematic

19.	Overall school performance	0	1	2	3

20.	Reading	0	1	2	3

21.	Writing	0	1	2	3

22.	Mathematics	0	1	2	3

23.	Relationship with parents	0	1	2	3

24.	Relationship with siblings	0	1	2	3

25.	Relationship with peers	0	1	2	3

Date	Score

Date	Score

Date	Score

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The patient information leaflets are provided by Vigilance Santé Inc. This content is for information purposes only and does not in any manner whatsoever replace the opinion or advice of your health care professional. Always consult a health care professional before making a decision about your medication or treatment.

Attention Deficit / Hyperactivity Disorder (ADHD) Monitoring Form

Attention Deficit / Hyperactivity Disorder (ADHD) Monitoring Form

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