Thank you for your time
ADHD, behaviour, mood and schooling difficulties are clinical diagnoses, and do NOT need expensive scans and laboratory tests.The information that you provide in this form is vital and fundamental in making the correct diagnosis and formulating a management plan. Few other adults will spent more time with their children than their teachers, mainly if the child is of elementary school age. The teacher's opinions are critical in evaluating any child.
School currently attending.
Is this evaluation based on a time when the child is on medication?
was on medication
was not on medication
A few teachers may feel some questions are not appropriate for high school children. These questions are international rating scales used by TEACHERS In North and South America, , Europe, Australasia and Africa. I you feel some questions do not apply to your learner, then simply reply NEVER or Non Applicable.
1.Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand).
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn (waiting in line)
18. Interrupts or intrudes on others’ conversations and/or activities
19. Loses temper
20. Actively defies or refuses to comply with adult’s requests or rules
21. Is angry or resentful
22. Is spiteful and vindictive
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (eg, “cons” others)
26. Is physically cruel to people
27. Has stolen items of value
28. Deliberately destroys others’ property
29. Is fearful, anxious, or worried
30. Is self-conscious or easily embarrassed
31. Is afraid to try new things for fear of making mistakes
32. Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
35. Is sad, unhappy, or depressed
Somewhat a Problem
38. Written Expression
School Situations Questionnaire.
Instructions: Does this child present any problems with compliance to instructions, commands, or rules for you in any of the following situations? If so, please select next to the situation and rate how severe the problem is for you using the adjacent 1–9 scale, ranging from mild to severe if this child does not present a problem in a given situation, select No and go on to the next item on the form.
School Situations Questionnaire.
When arriving at school
During individual desk work
During free playtime in class
During class lessons
In the hallways/corridors
In the bathroom
On school trips
Classroom Behavioural Performance.
Somewhat a Problem
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organisational skills
Overview of classroom functioning.
Well Below Grade Level
Some what Below
At Grade Level
Some what above
Writing: Written syntax (sentence level)
Writing: Written composition (text level)
Mathematics: Computation (accuracy)
Mathematics: Computation (fluency)
Mathematics: Applied mathematical reasoning
Classroom Performance: Following directions/instructions
Classroom Performance: Organisational skills
Classroom Performance: Peer relationships
Classroom Performance: Classroom Behaviour
Are you concerned that the student might be struggling with a specific learning disability? The following are criteria based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) for identifying such issues. To confirm a learning disability, at least one of the following symptoms must have been present for a minimum of six months, even with targeted interventions. The symptoms should be noticeably below the expected level for the student's age and interfere with their schoolwork or daily activities. Please select all that apply.
Difficulty reading(e.g., inaccurate, slow and only with much effort).
Difficulty understanding the meaning of what is read.
Difficulty with spelling
Difficulty with written expression( e.g., problems with grammar, punctuation or organisation).
Difficulty understading number concepts, number facts or calculations.
Difficulty with mathematical reasoning (e.g., applying math concepts or solving math problems)
Strengths: What are this student's strengths?
Education plan: If this student has an education plan, what are the recommendations? Do they work?
Accommodations: What accommodations are in place? Are they effective?
Would s/he stand out from same-sex peers? In what way?
Individual seat work: How well does this student self-regulate attention and behaviour during assignments to be completed as individual set work? Is the work generally completed? Would s/he stand out from same-sex peers?In what way?
Transitions: How does this student handle transitions such as going in and out for recess, changing classes or changing clothing.
Conflict and Aggression: – Is s/he often in conflict with adults or peers? How does s/he resolve arguments? Is the student verbally or physically aggressive? Is s/he the target of verbal or physical aggression by peers?
Academic Abilities: We would like to know about this student's general abilities and academic skills.
Self-help skills, independence, problem solving, activities of daily living
Motor Skills (gross/fine): Does this student have problems with gym, sports, writing? If so, please describe.
Written output: Does this student have problems putting ideas down in writing? If so, please describe.
Primary Areas of concern: What are your major areas of concern/worry for this student? How long has this/these been a concern for you?
Impact on student: To what extent are these difficulties for the student upsetting or distressing to the student him/ herself, to you and/or the other students?
Medications: If this student is on medication, is there anything you would like to highlight about the differences when s/he is on?
Parent involvement: What has been the involvement of the parent(s)?
Are the problems with attention and/or hyperactivity interfering with the student's learning? Peer relationships?
Has the student had any particular problems with homework or handing in assignments?
Is there anything else you would like us to know? If you feel the need to contact the student's clinician during this assessment please feel free to do so
Satisfies criteria for Inattentive type ADHD
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