Teacher Follow-up ADHD form

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Child's Name *

First Name Last Name
School Name *
School currently attending.
School Email *
example@example.com
Teacher's Name *

First Name Last Name
Teacher's Email *
example@example.com
Grade *
Today's Date

Day Month Year
Date
Additional information about type of class *
Normal stream. Remedial. Or specialised class
Please indicate in months time you have been able to evaluate the behaviours: *
Is this evaluation based on a time when the child is on medication? *

was on medication was not on medication not sure
I have read and accepted the terms of use, privacy policy, and sharing of personal information policy on the drflett.com website in terms of the South African POPI act. *

I accept

Name of medication, dose of each tablet, total dose per day if you know

	Never	Occasional	Often	Very Often
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