• Child/Teen ADHD Questionnaire

    Observations of a minor by parents, teachers, guardians
  • Relationship to patient

  • Format: (000) 000-0000.

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    Staff cell: 616-635-3713

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  • Progress since last visit*
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  •    
    • Section 1  
    • 1. Doesn't finish things*
    • 2. Doesn't pay attention*
    • 3. Doesn't seem to listen*
    • 4. Difficulty following instructions*
    • 5. Difficulty getting organized*
    • 6. Avoids doing things that require a lot of mental effort*
    • 7. Loses things*
    • 8. Easily distracted*
    • 9. Forgetful*
    • Section 2 
    • 1. Too much energy*
    • 2. Fidgety, restless*
    • 3. Interrupts, blurts out, immature responses*
    • 4. Acts without thinking, neglects consequences*
    • 5. Difficulty calming down once upset*
    • 6. Impatient, unable to wait turn*
    • 7. On the go, acts as if "driven by a motor"*
    • 8. Defensive, argumentative*
    • 9. Over-reacts, gets too excited or emotionally intense*
    • Section 3 
    • 1. Emotionally insecure, vulnerable*
    • 2. Appears depressed*
    • 3. Anxious, fearful, panicky*
    • 4. Worries about future events, inadequacy, failure*
    • 5. Over-reacts, gets too excited or emotionally intense*
    • 6. Meticulous, perfectionist*
    • 7. Pessimistic, sees worst side of situations*
    • 8. Quick to perceive social rejection*
    • 9. Low self-esteem*
    • Section 4 
    • 1. Dissatisfied, unhappy with life*
    • 2. Trouble completing homework, chores, responsibilities*
    • 3. Symptoms interfere with friendships, social development*
    • 4. Sleep problems--insomnia, daytime tiredness, irregular sleep*
    • 5. Symptoms interfere with learning*
    • 6. Symptoms interfere with family function*
    • Should be Empty: