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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Attention Deficit / Hyperactivity Disorder (ADHD) Monitoring Form

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